BACKGROUND: Historically marked by a high infant mortality rate, Sweden's healthcare reforms have successively led to a robust, decentralized universal child health system covering over 97% of the population 0-5 years. However, inequities in health have become an increasing problem and the public health law explicitly states that health inequities should be reduced, resulting in various government initiatives. This study examines the experiences of Central Child Health Services (CCHS) teams during the implementation of the Child Health Services Accessibility Agreement between the State and the regions starting in 2017. The agreement aimed to enhance child health service accessibility, especially in socio-economically disadvantaged areas, but broadly stated guidelines and the short-term nature of funding have raised questions about its effectiveness. The aim of this study was to understand the experiences of CCHC teams in implementing the Child Health Services Accessibility Agreement, focusing on investment decisions, implementation efforts, as well as facilitators and barriers to using the funds effectively. METHODS: CCHC teams were purposefully sampled and invited via email for interviews, with follow-ups for non-respondents. Conducted from January to October 2023, the interviews were held digitally and recorded with individuals familiar with the agreement's implementation within these teams. Both authors analyzed the transcripts thematically, applying Braun and Clarke's framework. Participants represented a cross-section of Sweden's varied healthcare regions. RESULTS: Three main themes emerged from the thematic analysis: "Easy come, easy go," highlighting funding uncertainties; "What are we supposed to do?" expressing dilemmas over project prioritization and partner collaboration; and "Building castles on sand," focusing on the challenges of staff retention and foundational program stability. Respective subthemes addressed issues like fund allocation timing, strategic decision-making, and the practical difficulties of implementing extended home visiting programs, particularly in collaboration with social services. CONCLUSIONS: This study uncovered the challenges faced in implementing the Child Health Services Accessibility Agreement across different regions in Sweden. These obstacles underline the need for precise guidelines regarding the use of funds, stable financing for long-term project sustainability, and strong foundational support to ensure effective interprofessional collaboration and infrastructure development for equitable service delivery in child health services.
Pamela MorrisâPerez, Rachel M. Abenavoli, Adam Benzekri, Sarah RosenbachâJordan ¡ 5 authors
For much of the past decade, suicide has been the second leading cause of death for adolescents in the United States, and suicide rates among adolescents have been rising for the last 15 years. Suicidal thoughts and behaviors among adolescents were common before COVID-19 and have become an increasing public health priority in the pandemicâ˛s wake. In this Social Policy Report, we review evidence for suicide prevention strategies designed to address these rising trends. We make recommendations for federal, state, and local policymakers and practitioners; program developers in organizations that design and implement programming for youth; and academic and nonacademic researchers. Where research evidence is strong, we suggest legislation, funding, and implementation. In areas where gaps in evidence exist, we recommend program development and research. Our recommendations follow the order in a taxonomy adapted from the Centers for Disease Control and Prevention, beginning with strategies that change the structural conditions in which adolescents live and concluding with strategies that support adolescents following a suicide (i.e., postvention). We find strong evidence for, and recommend policy implementation of: restricting access to lethal means; LGBTQ+ affirming policies; screening for suicide risk in medical settings; and community-wide investments via the Garrett Lee Smith Memorial Act. In schools, we find benefits of, and recommend funding and implementation of, youth-focused programs. Even so, gaps exist: (a) research on economic policies for adolescents is nonexistent; (b) while mental health care access is a barrier, we do not know how to reduce youth suicide rates via changing care access; (c) data on crisis lines are encouraging but descriptive; and (d) school personnel training increases knowledge and confidence but not adolescent help-seeking. Finally, guidelines for response following a suicide loss focus on immediate support and are based on limited research; this is an area for program development and research. We recommend state-level policymakers restrict access to firearms via regulations and safe storage; public health officials implement firearm safe storage programs and build barriers on buildings/bridges; public health officials and health care providers distribute lockboxes for medications; and the Consumer Product Safety commission enact regulations that restrict the size of bottles for lethal over-the-counter medications. We recommend that state-level policymakers protect and implement strategies that treat LGBTQ+ youth equally and affirm LGBTQ+ identities (e.g., maintain same-sex marriage laws, protect affirming school environments/safe spaces for LGBTQ+ youth); state policymakers and school district/school leaders fight anti-LGBTQ+ legislation, policy, and practices that limit access to medical care, sports, representation in classroom conversations; and school leaders support LGBTQ+ affirming spaces (e.g., GSAs). We recommend that The Joint Commission1 update its recommendations to include universal suicide risk screening for adolescents; the Centers for Medicare & Medicaid Services at the Department of Health and Human Services require screening for suicide risk in pediatrics and emergency departments as part of routine care; and health care providers implement such screening practices. We recommend that the federal government increase funding for the Garrett Lee Smith Memorial Grants that provide funding to communities for suicide prevention activities in youth-serving organizations and for the Suicide Training and Awareness Nationally Delivered for Universal Prevention (STANDUP) Act of 2021 that offers suicide prevention funding to schools to implement effective programs. We also recommend that public health and school district leaders apply for such funding and implement evidence-based practices. We recommend that state and local policymakers fund and monitor school district- and school-level implementation of state-wide suicide prevention laws and that school district/school leaders ensure implementation of such laws. We recommend that the state and federal Departments of Education fund and encourage implementation of evidence-based school youth-focused programs,2 in tandem with school staff training programs, and that school district/school leaders implement such programs. We recommend that the National Committee on Vital and Health Statistics create national standards for suicide death classifications and require workforce training to reduce variation across place and persons that can lead to underreporting for minoritized racial/ethnic and LGBTQ+ groups. We also recommend that public health officials ensure that coroners and medical examiners receive such training. Engage peer leaders to spread messages of help-seeking as normative in schools, in youth-serving organizations, and on social media. Develop programs that address unique needs of groups at high risk (e.g., Indigenous, multi-racial, LGBTQ+, and rural adolescents). Also develop programs for racial/ethnic minority youth for whom there is limited Develop programs that support adolescent needs for and for the youth in the design of programs, youth and youth to Develop strategies that support the of adolescents have the loss of a peer to and research on the of economic policies to reduce on adolescent suicide death and research on policies and practices (i.e., and for minoritized racial/ethnic groups Indigenous, and adolescents). and on the of increasing mental health care on adolescent suicide on the of crisis across in implementation across and to recommendations for practices and gaps in program design and the of effective peer programs on minoritized racial/ethnic and LGBTQ+ adolescents and in a of school and to data for of suicide and thoughts and and that of and policy in Our on the following youth the of and thoughts suicide and thoughts of to and suicide do not include is an in which with an to but not is the for suicide research. The suicide is with in part of its as a and We the following for of thoughts and behaviors among which to the of suicide as a suicide that as a of the suicide social that an for of risk among in social groups. 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Consumer Product Safety regulations that restrict size of bottles for lethal over-the-counter medications. policies and of same-sex marriage laws suicide among high school for and practices affirming LGBTQ+ youth on policies for minoritized racial/ethnic groups is and and implement strategies that treat LGBTQ+ youth equally and affirm LGBTQ+ identities (e.g., maintain same-sex marriage laws, protect affirming school for LGBTQ+ policymakers and school district/school anti-LGBTQ+ legislation, policy, and practices that limit access to medical care, sports, representation in classroom LGBTQ+ affirming spaces (e.g., GSAs). research on (i.e., for minoritized racial/ethnic groups. mental health and increase access to mental health care and access to health laws increase mental health care and for access is of there is limited research on the of access on suicide rates of crisis lines to are but lines in are following but there is evidence of the of crisis lines on suicide training and to for is for adolescents). and on the of increasing mental health care on adolescent suicide on the of crisis across national implementation of crisis in implementation across and to recommendations for practices and gaps in program design and adolescents at risk in suicide prevention in schools and youth-serving organizations peer and change universal screening is in medical adolescents that not lead to and The Garrett Lee Smith Memorial Act of for a of youth suicide prevention across in communities and has been to The Act of 2021 offers suicide prevention funding to schools to implement effective programs. in school laws and there is variation in implementation at the district Training school personnel to and adolescents in schools increases knowledge and confidence but not adolescent help-seeking. Training in schools is at and programs peer programs have not been for on minoritized LGBTQ+ racial/ethnic groups. focus on the and youth to care, with to adolescent needs for and a programs youth to in the design of program and The Joint recommendations to include universal suicide risk screening for Centers for Medicare & Medicaid Services at the Department of Health and Human screening for suicide risk in pediatrics and emergency departments as part of routine such screening practices. and funding for the Garrett Lee Smith Memorial Grants and the Suicide Training and Awareness Nationally Delivered for Universal Prevention (STANDUP) Act of health and school district for such funding and implement evidence-based practices. and and local and monitor school district- and school-level implementation of state-wide suicide prevention laws. district/school implementation of such laws. and and federal departments of and encourage implementation of evidence-based school youth-focused programs, in tandem with school staff training programs. district/school such programs. Engage peer leaders to spread messages of help-seeking as normative in schools, in youth-serving organizations, and on social media. Develop programs that address unique needs of groups at high risk (e.g., Indigenous, multi-racial, LGBTQ+, and rural adolescents). Also develop programs for racial/ethnic minority youth for whom there is limited Develop programs that support adolescent needs for and youth in the design of programs, youth and youth to the of effective peer programs on minoritized racial/ethnic and LGBTQ+ adolescents and in a of school and and suicide and for prevention a suicide to a suicide death is with and national guidelines reduce such research to the benefits of guidelines a suicide guidelines are on crisis response support and are based on limited research. 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In schools, we find benefits of, and recommend funding and implementation of, youth-focused programs, at and changing social Even so, gaps exist: (a) research on economic policies for adolescents is nonexistent; (b) while mental health care access is a barrier, we do not know how to reduce youth suicide rates via changing care access; (c) data on crisis lines are encouraging but descriptive; and (d) school personnel training increases knowledge and confidence but not adolescent help-seeking. 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In VavĹiÄka and Others v the Czech Republic,1 the Grand Chamber of the European Court of Human Rights (âthe Courtâ) considered for the first time whether compulsory childhood vaccination can be compatible with the European Convention on Human Rights (ECHR). The majority2 found the Czech Republicâs vaccination policy to be âfully consistent with the rationale of protecting the health of the populationâ3 and within the wide discretion (âmargin of appreciationâ) given to Member States on health issues.4 The policy struck a fair balance between the protection of children against serious diseases and the protection of families from the consequences of refusal. Dissenting Judge Wojtyczek agreed that mandatory vaccination can be Convention-compliant but argued that the facts did not support such a conclusion in this case. He thought that the majorityâs consideration of the public interest did not give adequate weight to the best interests of individual children, as opposed to the interests of children in general, or to the particular risks, costs, side effects and benefits5 of each vaccine as opposed to the âgeneral consensus over the vital importance of this means of protecting populations against diseasesâ.6 Filed before the COVID-19 pandemic, the case will be of broad interest given the long-term political and legal debate around compulsory childhood vaccination. Whilst the UK is one of several European countries7 which maintain a voluntary vaccination programme, a growing number impose restrictions on voluntariness.8 Moreover, there is emerging evidence of a link between mandatory vaccination and a higher uptake of vaccinations and reduction in disease.9 We explore the reasoning in the judgment and its implications for childrenâs rights and in the debate around COVID-19 vaccination. In the Czech Republic, the Public Health Protection Act 2000 and an implementing ministerial decree require childhood vaccinations against nine diseases.10 If parents do not comply without good reason, they commit an offence and may be subject to sanction. The first applicant, Mr VavĹiÄka, was fined when he refused to have his 14 and 13-year-old children vaccinated against poliomyelitis, hepatitis B and tetanus as required by the State. The domestic courts dismissed his appeals. The other five applicants refused some or all of the nine vaccinations, resulting in their childrenâs exclusion from preschool. The NovotnĂĄs, for example, declined the measles, mumps, rubella (MMR) vaccine for their daughter, who was consequently refused admission to preschool on the ground that she posed a health risk to the other children. Their challenge in the domestic courts was also unsuccessful. The Chamber relinquished jurisdiction to the Grand Chamber of 17 judges due to the serious and controversial nature of the questions raised. Several governments11 and non-governmental organisations were given leave to intervene. Some of those governments (notably France, Poland and Slovakia) also restrict voluntariness. Indeed, the Court noted a European trend towards mandatory vaccination âdue to a decrease in voluntary vaccination and a resulting decrease in herd immunityâ.12 The Court did not consider there to be âany appearance of a violationâ of Articles 2, 6, 13 or 14 of the Convention.13 Nor was there found to be a breach of Article 9, which protects the right to freedom of religion and conscience. Most of the judgment is given over to the potential violation of Article 8. Article 8 is a right in two parts. To show a violation, Article 8(1) must be engaged, and there must be no justification under Article 8(2). Article 8(1) states that âEveryone has the right to respect for his private and family life, his home and correspondenceâ. Previous judgments of the Court make clear that compulsory vaccination constitutes such an interference,14 and the Court accepted that this was so in VavĹiÄka.15 Article 8(2) qualifies the Article 8(1) right. This means that public authorities can interfere with the right where it is justified on the basis that it is lawful, pursued in accordance with one of the legitimate aims set out in Article 8(2) (which include inter alia the protection of health and the protection of others), and is ânecessary in a democratic societyâ. Applying Article 8(2), the Court found there was no violation of Article 8. It was âin accordance with lawâ because it was based on accessible domestic law, which made the requirement and penalties for non-compliance clear.16 It followed a legitimate aim because it protects the health and the human rights of others: the objective of the relevant legislation is to protect against diseases which may pose a serious risk to health. This refers both to those who receive the vaccinations concerned as well as those who cannot be vaccinated and are thus in a state of vulnerability, relying on the attainment of a high level of vaccination within society at large for protection against the contagious diseases in question.17 The requirement of necessity merits further explanation. An interference with Article 8(1) is ânecessaryâ to achieve a legitimate aim (the protection of health and the protection of others, in this case) if it answers âa pressing social needâ in a manner proportionate to the legitimate aim pursued. The Court recognised a wide margin of appreciation in relation to health issues, particularly those involving âsensitive moral or ethical issuesâ, such as compulsion.18 The Court accepted that: there is a general consensus ⌠that vaccination is one of the most successful and cost-effective health interventions and that each State should aim to achieve the highest possible level of vaccination among its population âŚ. Accordingly, there is no doubt about the relative importance of the interest at stake.19 The value of childhood vaccination rendered compulsion an acceptable mechanism in answer to a pressing social need, particularly in the light of the positive obligation of States to protect citizensâ lives and health.20 As we shall explore below, it was pertinent that childrenâs collective and individual best interests21 âare of paramount importanceâ.22 Also relevant to establishing that an interference is ânecessaryâ is the proportionality of the action to the legitimate aim pursued. Proportionality was of central importance in VavĹiÄka. It was assessed in relation to the particular facts in the various applications before the Court rather than in a wider abstract sense.23 Relevant factors included (inter alia) the limited number of vaccines mandated (nine), the exemptions that apply with respect to contraindications and conscientious objection,24 the nature of the compulsion which does not force compliance if people are willing to accept the fines and limitations on preschool provision,25 the effectiveness of the vaccinations in question,26 the availability of adequate compensation,27 and their safety record.28 Regarding the last of these, the Court heard that out of 100,000 children vaccinated annually in the Czech Republic, there were five or six cases of serious adverse effects.29 They are rare but serious, and so the Court reiterated30 the importance of taking precautions before vaccination. Precautions include checking for contraindications in each case and safety monitoring. In the case before it, the Court accepted that national methods kept the vaccines âunder continuous monitoring by the competent authoritiesâ.31 The Court also considered the nature of the penalties imposed for non-compliance. The fine was not excessive and did not impact on Mr VavĹiÄkaâs childrenâs education.32 With regard to the other applicants, it was accepted that the refusal of a preschool place impacted the opportunities afforded to the young children, but this âchoiceâ could be avoided by accepting the legal duty to vaccinate.33 The Court considered that the impact was time-limited, and the parents in the cases before the Court were able to ensure their childrenâs development in other ways. In sum, invoking the argument of a duty of easy rescue,34 which applies when the cost of acting is minimal and the benefits to others are significant, the Court said: [I]t cannot be regarded as disproportionate for a State to require those for whom vaccination represents a remote risk to health to accept this universally practised protective measure as a matter of legal duty and in the name of social solidarity for the sake of the small number of vulnerable children who are unable to benefit from vaccination.35 As is evident from this quotation, the Court endorses the basis of the Czech Republicâs compulsory vaccination policy: 36 Solidarity towards the most vulnerable.37 Submissions from the German Government also emphasised the principle of solidarity in the formation of their policy, which requires proof of measles vaccination, immunity or evidence of contraindication as a prerequisite for enrolment in schools, subject to a penalty of EUR 2,500 and exclusion from educational institutions:38 Compulsory vaccination aimed to protect not only those vaccinated but also society as a whole and, in particular, vulnerable persons who cannot be vaccinated themselves on account of their age or state of health.39 The appeal to solidarity is interesting. It has one of its most obvious applications, as here, within the public health context. When we return to the context of the United Kingdom, however, the principle of solidarity is less familiar. It also needs to be carefully distinguished from other notions, such as those of reciprocity and justice. Hence, the claim is not that it is fair to distribute the burdens and benefits of vaccination in a certain way, nor that the vaccination of some is owed in reciprocity to those vulnerable to disease. A helpful definition of solidarity that does distinguish it from these other terms is given in the Nuffield Council on Bioethics Report, Solidarity: Reflections on an Emerging Concept in Bioethics, where it is stated to be âshared practices reflecting a collective commitment to carry âcostsâ (financial, social, emotional or otherwise) to assist othersâ.40 As the Report makes clear, solidarity is both a description of the nature of certain practices and a prescription of these as ideal. In other words, solidarity characterises what is valuable about certain social forms and what is needed to maintain their valued character. In simpler terms, solidarity is about all being in it together and, as a result, all being prepared to share the burdens of a collective enterprise. On this account, immunising children against infectious diseases is justified because this ensures that everyoneâall children and, indeed, the rest of society to which any child belongsâbenefits. This is not best understood as being about balancing individual and collective benefits and burdens. Instead, it is about protecting what matters in our society: that we are all bound together by shared ties, and everyone must play their part in maintaining those ties. Solidarity is an important ideal and has had noticeable appeal in the current pandemic, where the need to secure high levels of vaccine take-up across society is pronounced. Judge Wojtyczek, however, points out that the case for social solidarity as a justification for mandate is most robust in relation to infectious disease. It is less relevant to tetanus, one of the nine mandated vaccines in VavĹiÄka, which is not contagious and where vaccination has no bearing on herd immunity. Solidarity is not wholly irrelevant as long as tetanus remains a public health issue41 and as long as the goal extends to solidarity between countries with the aim of reducing global health inequalities. Nevertheless, this was not explored in VavĹiÄka, where solidarity is inadequately defined. Moreover, the ideal sits oddly alongside any talk of interests and rights when these are understood in terms of what each individual, considered in isolation, may lay claim to. Indeed, it is hard to see how one might justify the compelled vaccination of children by appeal both to solidarity and to the best interests of the child, especially if the latter is understood to be paramount. In VavĹiÄka the Court said: It is well established in the Courtâs case-law that in all decisions concerning children their best interests are of paramount importance. This reflects the broad consensus on this matter âŚ. It follows that there is an obligation on States to place the best interests of the child, and also those of children as a group, at the centre of all decisions affecting their health and development.42 The decision is based on both the collective and individual interests of children. The Court speaks of the best interests of children being of paramount importance, but refers in the same paragraph to Article 3 of the United Nations Convention on the Rights of the Child, which says âIn all actions concerning children ⌠the best interests of the child shall be a primary considerationâ (our italics). Dissenting Judge Wojtyczek found this aspect of the majority judgment problematic. He argued that: [T]he central question around the best interests of the children is not whether the general health policy of the respondent State promotes the best interests of children as a group, but instead how to assess in respect of each and every specific child of the applicant parents ... whether the different benefits from vaccination will indeed be greater than the specific risk inherent in it.43 Yet, as is public health where what is at is the of to ensure the good health of a population rather than a cannot be rendered in the terms of the of between such as a and or and matters to such is whether the or to the and what is is the value of individual In the case of a young child, there can be no appeal to their children are not of such a child is not competent to parents and the make decisions on their taking the the what is is what is in the best children, their to if they are competent to do In and the a to competent childrenâs decisions to protect their best at where the decision or at A to a competent refusal of has recognised in the but is in Applying these general to childhood interests we should account of is It can each and every individual child, or it can the children as a collective In a public health what matters is the good of the the population as a This is the case with against infectious disease. the must be in place for a to be what is what a vaccination to to be vaccinated with population immunity In this it does not to in terms of individual of as well as the balance of and benefits to the population as a are also the majority in VavĹiÄka, this particular child is in their interests and also in the interests of all children, in as as a vaccine both protects against the relevant and to Indeed, if a vaccine does the a child indeed all the interests of who might the if our is a public health and we should account of the balance of and benefits across a whole each child is not justified by its being in their best interests being the we cannot that the best interest of the individual child is paramount where that means of greater weight than other as we have ethical of and of the of a interests are relevant and In and parents can vaccinations for young children. In about child vaccination between those with the must consider each child with his best interests as the paramount In such the courts have recognised that vaccination against the of a but with of or the child is in the is not a disproportionate breach of the Article 8 rights of the or the the courts have found in each case that vaccination is in the best interests of individual In a Court of decision said: vaccinations are not the evidence that it is in the best interests of children to be vaccinated in accordance with Public Health there is a specific in an individual Public Health a collective of the interests of children and on their can the collective interests of children the consideration of the best interests of the particular In what is childhood vaccination was no in VavĹiÄka because the children in each of the cases were not against their the parents were about the penalties The Nuffield Council on Bioethics Report on Public a the various a Government might to a public health goal should be from the to the most The the and the higher the the greater the required justification of the Public health it further should the means to achieve the required public health the public benefit of a vaccination is population immunity. a collective benefit can be if the benefit to each vaccinated individual is or If the public benefit can only be if of children are the question of what to ensure that this are proportionate and justified being the The question as young children cannot give their to being and in and their best interests are argued to be paramount. Proportionality was central to the but Judge Wojtyczek that greater should have given to the availability of less the Nuffield Council on Bioethics Report in that that and those that nor but and to In VavĹiÄka, were in both the to have their children vaccinated and the children a to This latter on the child by and on the by their childrenâs educational but the Court said: that was the of the made by their parents to to comply with a legal the of which is to protect in particular in that age The to a child is by the to the who are consequently not to the of Indeed, on this account, the balance of and benefits the The parents who not to their child have their freedom to make decisions for their Yet, no jurisdiction and no can to do what their the Courtâs of a wide margin of appreciation and limited on less the justification of the Czech policy in VavĹiÄka does not that could breach the Article 8 rights of children or The Court on the of compulsion rather than the but only because those effects were limited in the cases before This can be with justification of the controversial to require vaccination in where it was said: When vaccination is of as it is only in case a child is not vaccinated as by law, a penalty is imposed which may be followed by and The to this penalty no doubt in cases to vaccination where it be whether the penalty is or it does not vaccination in all If a is to the his child remains âŚ. could be made compulsory only by taking the child from the and it against his if he not or to its The effects of have the potential to the proportionality those who cannot the fine or for whom be without might be compelled in that those with greater some limitations on may pose only an interference with for example, of uptake is by rather than not a child does to serious to the child, the justification of childhood vaccination cannot be only in these as we have what does justify the of children is the fair of and benefits across a whole children from is in the interests of all and not the best interests of the child with The proportionality of is pertinent in the debate over COVID-19 In the vaccine out in not how we do We do by the Government a which will in The potential for of and will be relevant to as will the on that from vaccination to to and children be required to COVID-19 It is the first children to receive COVID-19 vaccination will be and so in the will be competent to their to vaccination. children and young will be children, both the risk of vaccination and the risk of COVID-19 is about the and of what is is the between the justification for childhood vaccination, which is clear and and the limited for the and both and long-term safety of all the individual COVID-19 vaccines in and indeed for the last of these in have in some COVID-19 vaccines that On a of vaccine in some countries for childhood it will be to see whether the to the pandemic, both for and in the vaccine is is whether the of COVID-19 will higher in the population without national If this and their parents may have a claim to vaccine and be willing to accept any of vaccine and have argued for mandatory COVID-19 vaccination in all children. They that it is in childrenâs individual and collective interests to receive COVID-19 the duty to the child, the duty of easy the duty to protect child by children from the and effects of and this argument is by the current of evidence for safety and in for example, the which is not mandated in countries in child definition is is not the its such State over citizensâ in terms of the of their and has the pandemic, which might public of any of vaccine children the to for is Judge Wojtyczek, in his argued that parents are in the best to childrenâs best In countries such as the United that a voluntary vaccination policy, the on rights to is in the case of v for example, to to interfere with decisions about their childrenâs and in said: [I]t is a principle of family in this jurisdiction that for decisions about a child rest with his In most the parents are the best people to make decisions about a child and the State whether it be the or any other public has no with the of the child is or is to as a of the given to the child not being what it be to a to Whilst in and about have thus in of vaccination on the basis that this is the that is in the best the decision in VavĹiÄka that the to State mandate is but a small Indeed, it is an the UK Government was before the VavĹiÄka will impact on the of It has a on solidarity that is in the United and which It has individual best interests with the collective interests of In particular, this judgment the that best interest must be considered should be understood both as the individual child and as the collective of all children. is in the interests of the child who is vaccinated and all other children who benefit from the general of a there are of compulsion and should and be and might proportionate and the COVID-19 has the and impact on in the of an Whilst the has not vaccine it has the potential of vaccinations to and social We the support of the which has two of the in a on ethical and in the pandemic,
Do adolescents have the decisional capacity of adults? Or, are they in crucial ways still immature, that is, are they deficient decisionmakers? This question has been answered in quite different ways in medical versus criminal law. In medical law, an exception from the requirement of parental consent was crafted to allow adolescents to make decisions in restricted circumstances associated with quasi-medical emergencies. Over the last few decades, this exception has grown into an almost blanket acceptance of the decisional capacity of adolescents under the age of 18 and generally over the age of 14 to give valid consent to treatment. At the same time, a seemingly contrary view of the decisional capacity of minors developed in American criminal law, especially around cases such as Eddings v. Oklahoma (1982), Johnson v. Texas (1993), Roper v. Simmons (2005), Graham v. Florida (2010), Jackson v. Hobbs (2012), and Miller v. Alabama (2012). These Supreme Court decisions recognize adolescents as having a substantive lack of maturity and an underdeveloped sense of responsibility that distinguishes adolescents from adults. The Court in Graham v. Florida (2010) noted, for example, that âdevelopments in psychology and brain science continue to show fundamental differences between juvenile and adult minds . . . [in] parts of the brain involved in behavior controlâ (560 U.S., at __ [slip op., at 17]). The result is that courts have accepted the view that the decisional capacity of adolescents is not fully developed and that as a consequence adolescents cannot have the same degree of criminal culpability as adults. In evaluating the decisional capacity of minors, one thus faces the challenge of how to harmonize these two quite different trends in the assessment of adolescent decision making. This issue of The Journal of Medicine and Philosophy brings together psychological and neurophysiological data with philosophicalâbioethical reflections on what should count as decisional capacity or decisional agency. Some of the articles address as well the issue of the authority of parents over their children and how this bears on the question of whether adolescents under the age of 18 should generally make medical decisions without the involvement of their parents. The conclusions one reaches on these matters regarding adolescent decisional capacity and parental authority will determine the concrete character of medical law and public policy. In particular, it will determine whether the default position should be that of presuming that minors over the age of 14 do or do not possess decisional capacity equivalent to that of adults. Where one places the burden of proof will also turn on empirical data regarding the contribution of authoritative, even authoritarian, parenting to the successful maturation of minors into adults, for this will give a further indication of the importance of parental involvement. This issue of The Journal of Medicine and Philosophy opens with a paper from a psychologist who has been involved in developing briefs to the Supreme Court (Miller, 2012) that have influenced holdings that recognized the diminished legal culpability of adolescents (Miller v. Alabama, 2012). Laurence Steinberg in his article âDoes Recent Research on Adolescent Brain Development Inform the Mature Minor Doctrine?â argues that, because adolescents are less mature than adults, when making decisions characterized by emotional arousal and peer pressure as when committing crimes, culpability is diminished (Steinberg, 2013). However, Steinberg also argues that recent studies of the adolescent brain and of behavioral development do not undermine the mature minor doctrine. Instead, the data indicate important ways in which the doctrine should be applied. First, Steinberg stresses the difference between adolescents and children, making plausible the old rule of 7âs (i.e., infants under 7 years, children 7â14, and adolescents over 14). He holds that adolescents in the right circumstances have decisional capacity equivalent to that of adults. Second, Steinberg takes the view that healthcare practitioners can enhance the ability of adolescents to make informed and knowledgeable decisions by being involved in the decisional process and by creating a context that circumscribes impulsive decision making (i.e., decision making that does not take into account long-term as well as short-term consequences of alternative courses of action). Thus, given peer pressure and circumstances in which impulsive decision making is not counteracted, adolescents lack adult decisional capacity and, therefore, adult culpability with regard to criminal acts. However, Steinberg argues that in the context of most medical decision making, adverse influences on the decisional capacity of minors can be counteracted so that adolescents can function as mature minors. In contrast, Evan Wilhelms and Valerie Reyna advance grounds to restrict the mature minor exception to quasi-emergency situations. They come to this decision because they find a more fundamental qualitative difference between adolescent and adult decision making. In âFuzzy Trace Theory and Medical Decisions by Minors: Differences in Reasoning between Adolescents and Adults,â they report data that show that it is not merely impulsive behavior or even the failure of adolescents to take into account long-term as well as short-term consequences that makes adolescents bad decisionmakers (Wilhelms and Reyna, 2013). More importantly, it is their failure to grasp the gist of what is at stake in making a decision. Wilhelms and Reyna develop their argument through engaging âfuzzy trace theoryâ: Fuzzy trace theory (FTT) is a comprehensive theory of reasoning, judgment, and decision-making that integrates the prior standard reactive model with documented cognitive developmental differences to explain risk-taking behavior in adolescents. . . . According to FTT, deliberative, analytic reasoning and impulsive reactivity are distinct routes to risk taking, and, surprisingly, the former accounts for a great deal of risk-taking in adolescence. . . . Thus, adolescents are not just more emotional and impulsive than adults; their understanding of the gist of such decisions is not mature. (Wilhelms and Reyna, 2013, 272) The point is that it is âgist processingâ that appears to be a necessary condition for mature decision making. Even when adolescents can intellectually analyze and lay out long-term as well as short-term consequences of their decisions, they still fail crucially to apprehend what is at stake in the decisions they face. Although adolescents are capable of encoding mathematical probabilities about risks and rewards, they still do not have the mature appreciation for the meaning of those risks and rewards, and their implications for their future adult lives. Put another way, it could be said that some adolescents know âthe price of everything but the value of nothing.â (Wilhelms and Reyna, 2013, 279) Adolescents, in short, differ qualitatively from adult decisionmakers, so that Wilhelms and Reyna âconclude that circumstances in which adolescents are equivalent to consenting adults are unusualâ (Wilhelms and Reyna, 2013, 270). They, therefore, recommend that âif [mature minor] exception is necessary for an emergency situation, the physician or medical experts involved should emphasize the bottom-line gist of risks involved during the process of consent or deciding on treatment optionsâ (Wilhelms and Reyna, 2013, 279). The next essay in this issue, âThe Mature Minor: Some Critical Psychological Reflections on the Empirical Basesâ (Partridge, 2013), takes a position closer to that of Wilhelms and Reyna than to that of Steinberg. This essay concludes that there are grounds to bring into serious question the advisability of exempting minors from parental authority and guidance, save in emergency or quasi-emergency circumstances, given the qualitatively different character of adolescent decision making. These differences are not just due to differences in decisional behavior, such that adolescents tend more than adults to be impulsive decisionmakers, who often inadequately take account of the long-term consequences of their choices and who very frequently fail fully to apprehend the significance of near- and long-range consequences of decisions. In addition, the brains of adolescents are simply different from those of adults. One can through brain imaging literally see the differences. When adolescents make decisions, there is a greater engagement of limbic structures with less of an engagement of prefrontal cortical areas in comparison with adults making the same decisions. These data justify a strong but rebuttable presumption that, in general, minors lack mature decisional abilities, and that they would benefit from the guidance of those who know them well, in particular parents and guardians. A second body of data is also relevant, which shows the importance of effective parenting for the maturation of adolescents (Baumrind, 1989; Adaljarnardottir and Hafsteinsson, 2001; Huver et al., 2007). These findings indicate that one should be more concerned about false positives than false negative determinations of decisional capacity, given the benefits from parental involvement. Here matters are complex, in that the character of the family in the West is changing, with some 41% of children in the United States now being born outside of a traditional marriage (Martin et al., 2011, 2). Any actual approach to adolescents will need frankly to take into account their social context. The papers by Rachelle Barina and Jeffrey Bishop, by Mark Cherry, and by Ana Iltis locate the examination of the mature minor exceptions more explicitly within moral and bioethical concerns. In their paper, âMaturing the Minor, Marginalizing the Family: On the Social Constitution of the Mature Minor, Sexual Politics, and the Family,â Barina and Bishop address the historic and social context in which the formation of the mature minor doctrine develops, and in doing so illustrate the adversarial nature between the goals of the state and the contextual role played by families. Barina and Bishop embed their analysis of this development within a âphenomenological account of the care of the body in the familyâ and its subsequent application to reproductive health policy. They argue that, legally and medically, the concept of the mature minor does not actually depend upon the notion of maturity. Instead, the invocation of the doctrine of âmature minorâ in the context of adolescent reproductive health has become a means to assert better health outcomes for the state. A careful consideration of maturity is unnecessary because contraception is an unqualified good in the case of every teen. Socially destructive and expensive health risks, more than the adolescentâs mature ability to understand and appreciate health information, merit the provision of reproductive health services without parental consent. (Barina and Bishop, 2013, 306) They also argue that the focus on public health to the exclusion of all other factors creates a clear conflict between state interests and parental authority. In so doing, the state is interrupting the conveyance of âthe moral, social, and existential goods that belong to the particular family within which the childâs life-world is formed.â (Barina and Bishop, 2013, 309) Mark Cherry takes a stronger stand against the universal application of the mature minor doctrine in his paper âIgnoring the Data and Endangering Children: Why the Mature Minor Standard for Medical Decision Making Must Be Abandoned.â Unlike Steinberg who is able to reconcile the apparent differences in the medical and legal understanding of adolescent decision making with the neuropsychological evidence, Cherry contends clearly that the mature minor doctrine must be abandoned. In his analysis of the neuropsychological data, Cherry argues in support of the Supreme Courtâs interpretation that adolescents make decisions qualitatively differently than adults. He writes: Current trends in pediatric decision making in support of the âmature minorâ standard constitute moral and legal movement in direct opposite to what the science bearing on the matter demonstrates to be reasonable and the United States Supreme Court judges to be constitutionally appropriate. To put the matter bluntly, the âmature minorâ standard for medical decision making ignores the scientific data and endangers children. (Cherry, 2013, 326) Ana Iltis examines both the decisional capacity of adolescents as well as the authority of parents over their children and the implications this has for adolescents giving consent. In her paper, âParents, Adolescence, and Consent for Research Participation,â Iltis (2013) concludes that adolescents often do not possess a decisional capacity that will allow sufficient appreciation of information so as to be able to give valid consent for participation in research, and indeed for consent to medical treatment generally. In part, she embraces this conclusion because of data that show that, although adolescents understand the information relevant to making a treatment decision, their appreciation or evaluation of reasonable and foreseeable consequences is usually different from that of adults. Here, Wilhelms and Reynaâs reflections through fuzzy trace theory regarding the importance of getting the gist of what is at stake in a decision may be crucial. Iltis advances as well a second claim, a moral one, that minors even if they are mature are still children, and that there are, therefore, strong principled arguments for recognizing parents as being in authority to guide their children. We confront again the complexity of the issues at stake in assessing the status of the mature minor. In controversy are not merely the facts of the matter regarding how adolescents make decisions but also moral and social issues, namely, how we should regard the relationship between children and their parents. The intersection of these two areas of contention compounds the disputes in pediatric bioethics regarding the status of children. The articles in this issue are not unanimous on any point. However, all the authors appear to concur that judgments regarding the decisional capacity of an adolescent will depend on the particular adolescent and the particular context. There are clearly significant variations among persons with respect to decisional capacity. In addition, persons do not take a uniform journey from infancy to mature adulthood. Some persons become mature decisionmakers much earlier than others, while others appear never fully to achieve this status. Sorting matters out will in part require further philosophical reflection on what we want to mean by mature decisionmakers. That is, we will need to reflect on the moral issue as to what characterizes a person who has decisional capacity. Bernat, Culver, and Gert (1981) in reflecting on the definition of death developed a distinction among concepts of death, criteria for death, and tests for death. A concept of death for them is a philosophical issue, a view of what it means to be dead (e.g., loss of personhood). A criterion of death involves an intersection of philosophy and physiology (e.g., a neurological criterion such as the irreversible cessation of all functions of the brain as an indicator of death). Tests for death are the actual diagnostic determinations employed by physicians in declaring death. We will likely need to fashion similar distinctions with regard to competency, so as to be clearer as to what should be compassed by the concept of decisional capacity as well as what should serve as criteria for crucial elements of decisional capacity such as, perhaps, âgist-processing.â We will need as far as possible to determine the necessary and sufficient capacities that can serve as criteria for competent decision making. Then we need to determine what one should look for when making the judgment that a person under the age of 18 but over the age of 14 has decisional capacity. These essays point the way to further work.
Open access
Ethics and Legal Issues in Pediatric Healthcare
Child and Adolescent Health
Child and Adolescent Psychosocial and Emotional Development
The topic of the above title has vividly interested the author for many years. Regretfully, the issues at stake have not changed for the last 25 years. As proof of this - and on purpose - references dug up and quoted are only those published before 1986. The end result has been the (re)construction of a scenario that has been stubborn to change and that looks into most of the burning questions of then and now pertaining to the title.The materials here presented are an informal, non-systematic review of the literature on the ethical, ideological and political implications of health as a science and as a praxis. The materials here collected are, in a way, "out of the box" and, in the author's view very needed. The article sheds some light on the major issues at the core of this universal discussion that - whether we like it or not - was and continues to be at the very base of our daily work as health professionals.
Jennifer Bryce, CĂŠsar G. Victora, JeanâPierre Habicht, Robert E. Black ¡ 5 authors
OBJECTIVE: To summarize the expectations held by World Health Organization programme personnel about how the introduction of the Integrated Management of Childhood Illness (IMCI) strategy would lead to improvements in child health and nutrition, to compare these expectations with what was learned from the Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact (MCE-IMCI), and to discuss the implications of these findings for child survival policies and programmes. DESIGN: The MCE-IMCI study designs were based on an impact model developed in 1999-2000 to define how IMCI would be implemented at country level and below, and the outcomes and impact it would have on child health and survival. MCE-IMCI studies included: feasibility assessments documenting IMCI implementation in 12 countries (1999-2001); in-depth studies using compatible designs in Bangladesh, Brazil, Peru, Tanzania and Uganda; and cross-site analyses addressing the effectiveness of specific subsets of IMCI activities. RESULTS: The IMCI strategy was successfully introduced in the great majority of countries with moderate to high levels of child mortality in the period from 1996 to 2001. Seven years of country-based evaluation, however, indicates that some of the basic expectations underlying the development of IMCI were not met. Four of the five countries (the exception is Tanzania) had difficulties in expanding the strategy at national level while maintaining adequate intervention quality. Technical guidelines on delivering interventions at family and community levels were slow to appear, and in their absence countries stalled in their efforts to increase population coverage with essential interventions related to care-seeking, nutrition, and correct care of the sick child at home. The full weight of health system limitations on IMCI implementation was not appreciated at the outset, and only now is it clear that solutions to larger problems in political commitment, human resources, financing, integrated or at least coordinated programme management, and effective decentralization are essential underpinnings of successful efforts to reduce child mortality. CONCLUSIONS: This analysis highlights the need for a shift if child survival efforts are to be successful. Delivery systems that rely solely on government health facilities must be expanded to include the full range of potential channels in a setting and strong community-based approaches. The focus on process within child health programmes must change to include greater accountability for intervention coverage at population level. Global strategies that expect countries to make massive adaptations must be complemented by country-level implementation guidelines that begin with local epidemiology and rely on tools developed for specific epidemiological profiles.
This study addresses the interprofessional training of professionals necessary to function in an integrated service delivery system for children and youth at risk. Information was collected in seven OECD member countries on current multidisciplinary training capabilities, including country information and exemplary program descriptions. A number of significant findings were identified from the study regarding national policies, effects of decentralization, organizing mechanisms, training components, implementation strategies and financing. Clear policy implications emerged from the study, including the need to incorporate national policies on training in the policy framework for serving children and youth at risk, encouraging universities to develop curricula relevant to coordinated systems of care for their children and youth, and establishing national mechanisms for supporting and linking local training initiatives.
<p>&#8220;Web3&#8221; is now part of our collective imaginaries, even if the specifics of what the buzzword entails remain murky and inaccessible to many. Originally coined in 2014 by Gavin Wood, co-founder of Ethereum, to describe &#8220;a decentralised internet ecosystem based on blockchain,&#8221; the term took off after the NFT boom of 2021, catalysed by the embrace of the crypto ecosystem by the likes of Silicon Valley venture capital firm Andreessen Horowitz (a16z).</p>\n<p>Like other social technologies, the swirl of narrative, attention and capital around web3 are as much part of its utility as the tools themselves. Mainstream discourses around &#8220;the web3 space&#8221;âand the blockchains, non-fungible tokens (NFTs), cryptocurrencies, decentralised web (dweb) frameworks that make it upâhave been shaped by a cacophony of criticism, partiality and hype, played out over the past five years on Twitter and Discord.</p>\n<p><em>Future Art Ecosystems 3: Art x Decentralised Tech (FAE3)</em> attempts to take a long(er) view on the impact of decentralised technologies and imaginaries on the structures and processes that underpin the development of 21st-century cultural infrastructure, specifically art and advanced technologies (AxAT). The downward slope of the hype cycle towards another &#8220;crypto winter&#8221;âas well as a market correction in the wider tech industryâis a good time to take a sober view of the lessons, potentials and affordances that have been generated over these years of energetic innovation and speculative boom and bust&#8230;</p>\n