Article Text

Download PDFPDF

Children of COVID-19: pawns, pathfinders or partners?
  1. Victor Larcher,
  2. Joe Brierley
  1. Paediatric Bioethics Centre, University College London Great Ormond Street Institute of Child Health, NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
  1. Correspondence to Dr Joe Brierley, Paediatric Bioethics, Great Ormond Street Hospital for Children, London WC1N3JH, UK; joe.brierley{at}gosh.nhs.uk

Abstract

Countries throughout the world are counting the health and socioeconomic costs of the COVID-19 pandemic, including the strategies necessary to contain it. Profound consequences from social isolation are beginning to emerge, and there is an urgency about charting a path to recovery, albeit to a ‘new normal’ that mitigates them. Children have not suffered as much from the direct effects of COVID-19 infection as older adults. Still, there is mounting evidence that their health and welfare are being adversely affected. Closure of schools has been a critical component of social isolation but has a far broader impact than the diminution of educational opportunities, as important as these are. Reopening of schools is therefore essential to recovery, with some countries already tentatively implementing it. Children’s interests are vital considerations in any recovery plan, but the question remains as to how to address them within the context of how society views children; should they be regarded as pawns, pathfinders or partners in this enterprise?

  • children
  • public health ethics
  • ethics

This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

https://bmj.com/coronavirus/usage
View Full Text

Statistics from Altmetric.com

Scientific and ethical guidance

As countries emerge from lockdown, the true effects of widespread social isolation can be assessed. Despite the overwhelming desire for a return to normality, a new ‘normal’ is required to both address those effects and to mitigate against them in any second wave.1 Covid-19 infection has been comparatively benign in children, but there is mounting evidence that their health and welfare have been aversely affected by social measures to control the pandemic.2

The UK response to COVID-19 has been guided by science, operating within an ethical framework developed in response to previous pandemic threats.3 Neither has given a great deal of consideration to the recovery process, though presumably similar ethical principles apply to plans to ease current restrictions, as they did to their implementation. There have been little scientific data to guide how children might be involved in the recovery from social isolation. COVID-19 seems to have, at least initially, affected children less severely than adults with <2% of infected children needing critical care and mercifully few deaths.4 5 But the extent to which they may be asymptomatic carriers is unclear, though they do not appear to be super spreaders. In this context, school closures may have a relatively small contribution in preventing the spread of the virus when compared with other social distancing techniques but have profound adverse socioeconomic effects.6 Also, the relationship between past exposure and consequent immune status is currently unknown, but plainly essential information in considering children’s potential part in the recovery process. The role of specific host defence factors, genetic factors, ethnicity and socioeconomic deprivation (the latter two parameters seemingly related to COVID-19 susceptibility and severity in adults) is also not known—though all are important in other childhood diseases. In the sense that they operate in childhood, they create additional jeopardy to any conferred by the state of childhood per se.

Ethical guidance so far issued makes no specific provision or concession for children—or indeed any vulnerable group, or those with instrumental value to society,3 but is founded on the principle of equal concern and respect. Application of the underpinning principles of inclusivity, respect, solidarity, proportionality and reciprocity necessarily entail that the interests of children are given as much weight by society as those of adults. For example, the principle of reciprocity requires that those risks others bear on our behalf be accounted for and ameliorated, such as in the provision of adequate personal protective equipment (PPE) for all who need it. It is not clear the extent to which application of this principle to children has occurred. Indeed, it may be the case that children effectively continue to be regarded as pawns, insofar as their interests can be sacrificed by others in pursuit of other goals—as they have in the past.7

Children as pawns

Traditional moral theories grant children limited moral status, broadly proportionate to their state of moral development; others have ethical and legal authority to make appropriate decisions on their behalf. Granting children rights confers some moral agency; the UN Convention on the Rights of the Child provides protection, welfare and education rights, irrespective of the child’s ability to claim them.8 This Convention would apply to children’s involvement in the recovery from lockdown, for example, return to school, even if a consequence was of significant concomitant benefit to adults such as the ability of parents to return to work, improvement of family social circumstances and mental health. It follows that children, even if they had no say in the process, should receive adequate protection, for example, by provision of appropriate public health facilities and social distancing. Any harms that might accompany a return to school should be minimised and balanced against those of remaining in lockdown. Adequate and appropriate PPE for staff and supporters is an essential requirement for all staged returns to school.

Nevertheless, contemporary thinking about childhood accords children more active roles and a voice in matters that concern them.

Children as pathfinders

A staged return to the ‘new normal’ might plausibly cast children in a pathfinder role. In World War 2, pathfinders were elite troops, often volunteers, with advanced technological equipment, who prepared the way for the main forces. In the case of children’s return to school, this might mean that older children, whose educational prospects and crucial examinations have been compromised, might lead the process, with appropriate safeguards, and use of technology such as track and trace apps. An additional reason for selecting older children might be that they are more likely to have the capacity to give valid consent for the use of technology and for minimally invasive testing, for example, swabs and blood sampling necessary to safeguard the process. Arguably they might be more likely to comply with hand hygiene social distancing and understand the need to do so.

If predetermined endpoints could document the efficacy and safety of this approach, it could be useful in extending the return to school more widely. It would also encourage the more active involvement of children in the process, be compatible with participation rights as granted by the United Nations Convention on the Rights of the Child (UNRC) and give participants a sense of inclusivity and partnership that would be of social utility.

Children as partners

It might seem to strain credulity to regard children as partners in the easing of lockdown; after all, they may lack the ability to define and claim the liberty rights that adults have.9 However, they will inhabit the new normal, with all its attendant socioeconomic changes, just as inevitably as adults will. In support of this concept of partnership and participation, article 12 of the UNRC requires children to be informed and consulted over matters that concern them and that their views be given due weight in accordance with their age and maturity.8 In recent years, children have become actively involved in healthcare,10 11 research12 and as activists for prevention of climate change.13 Some children have shown the capacity for self-directed acts of kindness and altruism, in keeping with a level of moral development that some adults may never achieve.14 In short, their evolving moral agency throughout childhood is unquestionable, and for many of serious weight before adulthood.

Because of the attendant uncertainties attached to the easing of lockdown, such as the existence of any second wave of infection and its containment, easing can be considered an experimental procedure in which children, in common with other groups, are de facto research subjects. Since children are increasingly active participants in the identification of research topics and the design and implementation of trials, it seems logical to include them in this ‘project’, especially as they will experience the future consequences of the pandemic. Indeed, the principles of equal concern and respect, and inclusivity appear to require this. Children in common with others need clear explanations of the risks and benefits of leaving lockdown in terms that they can understand. If future societies (including today’s children) are to retain trust in governmental strategies, it is essential that governments ‘show their working out’; the principles of ethical decision-making require transparency, accountability and reasonableness.

Conclusions

Society has a clear duty to protect children from the harms that the pandemic and the means to control it can cause. But, necessary as this is, children should be more than passive recipients of our concern, they are after all future citizens with a right to an open future.15 Post COVID-19, we need to build a new normal, that is a kinder, more inclusive and equal society, in which today’s children are to be active members. We should involve them in the process rather than consider them as mere pawns in a societal game of chess. However, we would do well to remember that ‘[pawns] are the soul of chess…on their good or bad arrangements depends the gain or loss of the party’,16—not such an inappropriate metaphor after all?

References

View Abstract

Footnotes

  • Contributors Both composed the manuscript. VL wrote the first draft and JB added to it, edited and finalised.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Data availability statement No data are available.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.