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date: 10 July 2020

Children, Adolescents, and Public Health: Ethical Considerations

Abstract and Keywords

The population of children and adolescents encompasses a remarkable range of physiological, developmental, and experiential phenomena. Considered from a global perspective, differences may seem to overwhelm similarities. This chapter proposes and explains three distinct but interrelated characteristics that should frame ethical considerations of public health approaches to children and adolescents: (1) lack of political, economic, and social power; (2) status as subject to stewardship by adults; and (3) presumed lack of capacity for decision-making.The impact of these shared characteristics is examined using public health approaches to health information, health promotion and access to confidential services. Public health policies that anticipate the risks related to powerlessness and failures of stewardship, and seek to promote respect for developing capacity can help to create conditions in which children can thrive.

Keywords: adolescents, children, stewardship, capacity, public health, power, decision-making, public health ethics

(p. 192) Introduction

Identifying and addressing ethical issues specific to the population comprising children and adolescents is complicated at the outset by definitional and data issues. Children and adolescents account for approximately a third of the extant population, and the age range encompasses such a broad set of physical, cognitive, and experiential characteristics that particularities seem hard to identify. This chapter proposes that there are three fundamental aspects of the experience of children and adolescents that should frame public health approaches: (1) lack of a social and economic power, (2) being subject to stewardship by adults, and (3) a presumed lack of capacity for decision-making.

Interestingly, there is no universal definition of a child or an adolescent. As noted in 1981 by the United Nations Advisory Committee for the first “International Youth Year,” “a chronological definition of who is young, as opposed to who is a child or who is an adult, varies with each nation and culture” (Angel, 1995, 133; UN, 1981). For statistical purposes, the United Nations identifies people aged fourteen to twenty-five as “youth,” while younger persons are “children.” Recent developments in psychology and neuroscience reflect the logic of including young adulthood as part of the developmental range from infant to adult (IOM and NRC, 2014). However, for purposes of policy and law, age eighteen is identified as the beginning of adulthood and the age of majority in most countries (CIA, 2013).

(p. 193) Adolescence, in most cultures, is a term related to puberty, which begins between ages eight and thirteen for girls and between ages nine and fourteen for boys. Adolescence is typically considered to be the period between the beginning of puberty and the onset of adulthood, but the onset of adulthood is socially, not physiologically, determined (United Nations Department of Economic and Social Affairs Population Division, 2012). While formal markers of adulthood, such as age of majority or ability to vote, vary only minimally between countries, the age at which typical experiential markers of adulthood, such as marriage, financial independence, and parenthood, are achieved varies widely between societies and cultures. The variations are not trivial: the experience of young people and the expectations placed on them follow, in large part, from social and cultural age norms. A teenage girl comfortably ensconced in a middle-class family in the United States has expectations of postsecondary education, a protective home environment, and delayed marriage and family. In the poorest areas of sub-Saharan Africa, however, only half the girls of primary school age attend school, and half of all births occur during adolescence (UNESCO, 2003; WHO, 2017a). A focus on the public health issues and the predominant ethical considerations of these complicated age and experience groups requires interpretation beyond the artificial categories of chronologic age, but such a focus can highlight shared experiential characteristics that have profound implications for public health.

Definitional complexities aside, UNICEF estimates that by 2050 there will be nearly 10 billion people in the world, and more than 2.6 billion of them will be younger than eighteen years of age. This is a slight trend downward in the proportion of the world’s population under eighteen. Children and adolescents are currently a majority in only the least-developed forty-eight nations. This trend will continue, with children and youth increasingly concentrated in areas where poverty is most entrenched. Interestingly, the actual number of very young children in the world is not well identified. This adds to the difficulty in identifying specific public health issues for this subset of the population, but it also highlights an important ethical concern: fully one-third of children under age five have no birth registration, meaning no state identity at all. These children, estimated at 230 million, are not part of any public health database, and they do not have a birth certificate to register for school, gain legal protection, or, in some areas, access health care. Severe disparities in this very basic benefit of being recognized exist, with almost half of the world’s poorest children under age five having no registered identity (UNICEF, 2013).

More positively, the best global estimates of mortality rates for children under age five imply that, for those children who are counted, mortality has been declining steadily for decades, going down by 50 percent between 1990 and 2015 (You et al., 2015). Disparities, however, are remarkable and persistent—the mortality rate for young children in low-income countries (76 per 1,000) is eleven times that in the richest countries (World Bank, 2015). The leading causes of death in children under five are preterm birth complications, pneumonia, birth asphyxia, diarrhea, and malaria. Globally, nearly half of under-five deaths are attributable to undernutrition (World Bank, 2015).

(p. 194) Older children and adolescents are the healthiest sector of the world’s population. Mortality rates are low, around 1 per 1,000, and there has been a slight decline in the mortality rate in the past decade. Adolescents tend to be at low risk for diseases that kill young children—such as diarrhea and respiratory disease (UNICEF, 2012)—but they suffer much higher mortality and morbidity from causes that reflect the stereotypical experience of adolescence, including violence, injury, and depression.

Globally, the leading causes of death among adolescents are motor vehicle crashes and road injury, HIV, suicide, lower respiratory infections, and interpersonal violence (Patton et al., 2009). Note that HIV deaths were not on the list of the top ten causes of death in adolescents in 2000, but they tripled between 2008 and 2018.

According to the WHO (2014), the major causes of morbidity in the late childhood and adolescent period include the following:

  • depressive disorders

  • iron deficiency anemia

  • asthma

  • back and neck pain

  • anxiety disorders

  • alcohol use disorders

Unlike the mortality rates for early childhood, the data for the adolescent sector of the population does not vary significantly between poor and wealthy countries or among geographic regions.

Life-course health development models, developed to emphasize the multiple, nested determinants of health, emphasize the trajectory of health or disease from the preconception period to childhood, to adolescence, and through to adulthood (Halfon and Hochstein, 2002). The World Health Organization estimates that 35 percent of the global burden of disease is related to the long-term outcomes of adolescent health and behavior (WHO, 2017b). Life-course models of health raise the stakes for a public health focus on the health of children and adolescents, as the benefits of early good health will support the well-being of a whole population, and the risks of early poor health persist throughout the life span (Sawyer et al., 2012).

Children and Adolescents

Given the differences in health concerns between children and adolescents, as well as the remarkable changes in physical, cognitive, and emotional attributes over this age span, it can seem simplistic to discuss this group as a particular population from the point of view of public health ethics. Children and adolescents are not a disease group. They are not identifiable by a specific incapacity, by any common dependency, or even by an intrinsic vulnerability.

(p. 195) Humans under the age of eighteen make up a “particular population” based on three distinct but interrelated characteristics—each having profound ethical implications for public health: (1) disenfranchisement and lack of social and economic power, (2) status as subject to stewardship, and (3) presumed lack of capacity for decision-making. This chapter will examine several public health challenges affecting children and adolescents with a view to these three defining characteristics and the practical and ethical tensions they create.

Disenfranchisement and Lack of Social and Economic Power

As minors, children and adolescents have no voting rights and no established political voice. As noted earlier, in some of the world’s poorest countries, more than half of young children have no birth registration, and hence no political or legal identity at all. The importance of a political identity was recognized in the Convention on the Rights of the Child, an international treaty adopted by the United Nations in 1989 that lays out the human rights of children. These include the right of every child to a name and legal and national identity—just after the right to life (UN, 1989). But even children and adolescents with established legal identities still have a very limited political voice. In their relatively powerless state, minors rely on the wisdom and foresight of those with power to enact and enforce policies that support their well-being. Essential conflicts arise when the interests of children are weighed against the interests of parents, families, or the state.

Article 3(1) of the Convention on the Rights of the Child states, “In all actions concerning children, . . . the best interests of the child shall be a primary consideration” (UN, 1989; emphasis added). Despite the powerful language of the Convention and its widespread acceptance, nations struggle to make the “best interests of the child” standard anything more than aspirational. In any political arena, there are many interests competing for limited resources, and the voice of the powerless is easily lost. Examples abound: while global morbidity and mortality statistics imply that the best interests of children require a focus on mental health for children and adolescents, resources fall far short of the need, competition for financial resources affects mental health disproportionately, and social stigma remains a significant barrier to care (WHO, 2003). Similarly, gun-related deaths and injuries remain a leading cause of morbidity and mortality in the adolescent and young adult age groups, but progress on gun control meets obstacles from increasing numbers of pro-gun lobby groups, and, particularly in the United States even research on the prevention of gun deaths, routinely falls prey to political interests (Wellford, Pepper, and Petrie, 2005). Despite evidence that simple programs to enhance maternal preconception health lead to healthier mothers and children, key components of these programs, such as maternal education and birth planning, fail to gain and maintain traction in the development of health and social policy (Moos, 2010; Africa Progress Panel, 2010).

(p. 196) Comparing Articles 3 and 5 of the Convention on the Rights of the Child offers insight into one of the potential conflicts of interest that weaken Article 3’s strongly worded “best interest” standard. Article 5 asserts, “States Parties shall respect the responsibilities, rights and duties of parents . . . to provide, in a manner consistent with the evolving capacities of the child, appropriate direction and guidance in the exercise by the child of the rights recognized in the present Convention” (UN, 1989; emphasis added). Article 5’s conflation of parental responsibilities with parental rights introduces the idea of stewardship and its limits on the best interest standard.

Stewardship and Ownership: The Rights and Duties of Parents

Within the family or community, the best interests of an individual child is a very high standard for acceptable decisions. In societies that promote and protect the importance of family, parents are presumed to have the right to raise a child according to parental cultural, religious, and philosophical values, along with the duty to provide an environment compatible with healthy development. Therein lies the challenge of “stewardship.”

Most societies have moved away from considering children as parental property or chattel, and children are now widely viewed as having moral status equal to their parents and, in some cases, an opportunity to be recognized as having decision-making authority. While the law in most countries asserts that parents must not violate the rights of their children, must not allow others to violate the rights of their children and should promote the interests of the child, it also gives parents substantial leeway in determining best interests and sets a high threshold for state infringement of parental rights. Instead of ownership, parents can be understood as having stewardship rights over their children, and as stewards they are charged with overseeing and protecting something of value that they do not “own” (Brennan and Noggle, 1997). Environmental stewardship, in a similar vein, does not imply that we cannot make use of the environment, but only that we are charged with protecting environmental resources and making any use sustainable. Stewardship is a limited duty; stewards are free to pursue their own interests as long as the stewardship obligations are fulfilled. Parents, correspondingly, are not asked to support the best interests of a child to the exclusion of their own interests. Parents, as stewards, evaluate their own interests alongside the interests of their children, seeking an appropriate balance (Austin, 2007).

Legal authorities do not generally hold parents to a best interests standard when evaluating the decisions made on behalf of a child. Instead, they apply the more practical “good enough interest” standard, offering parents broad leeway in parenting without state interference, and recognizing that within families there is a constant evolution in the balance of interests between children, parents, and family. The limit to parental authority over children is not a failure to promote best interests, but a material risk of avoidable harm to the child (Diekema, 2011). Within the stewardship model of parental obligations, some limited harms are acceptable when balanced against the well-being of the family.

(p. 197) Children thrive when parents, the community, and the state function as good stewards, making choices that promote the best possible interests of the child. Tremendous disparities exist, however, between families, between communities, and between nations in the extent to which children are protected and nurtured.

Presumption of Incapacity

The third unique characteristic that is common to children and adolescents is that of presumed incapacity. Essential to the logic of stewardship is the idea that children and adolescents are incapable of managing their own interests effectively and lack capacity for informed decision-making. The role of the steward is to protect the child while promoting and encouraging the development of independence. While the presumption of incapacity and the need for stewardship is clear and reasonable for much of early childhood, the ethical tensions rise as children develop independent skills and begin to approximate adult capacity for decision-making sometime in early or middle adolescence (Lipstein, Brinkman, and Fiks, 2015; Ruhe et al., 2015).

Public Health Challenges

Health Information and Health Promotion for Children and Adolescents

A mainstay of public health practice is the development and implementation of health promotion and health education programs. Challenges around health promotion activities arise from the competing duties to give children and adolescents access to developmentally appropriate information necessary to promote their own healthy development while avoiding harmful messaging, and to respect family and community values regarding the content and presentation of information.

Effective programs are targeted to specific populations and make use of salient characteristics of the target population. During childhood and adolescence, however, the only constant characteristic is change. The age range from childhood to adolescence involves remarkable transitions in cognitive capacity and emotional maturity. Successful health information and health promotion programs must be designed to incorporate capacity-specific messaging. For example, a smoking cessation program targeted toward the fourteen- to sixteen-year-old demographic must be mindful of the specific cognitive capacities of middle adolescence. Middle adolescence is marked by a heightened sense of anxiety about attractiveness, a newly emerging capacity for abstract thought, and a limited ability to consider the future. Concerns about long-term health complications of smoking are likely to miss the mark, while presentation of the negative effect of smoking (p. 198) on physical attractiveness will get attention. The same campaign directed toward early adolescents (ages ten to thirteen) should employ concrete logic and make use of early adolescents’ anxiety about being different from their peers, emphasizing that smoking makes a teen an outlier. The late adolescent to young adult group (ages seventeen to twenty-five) has a richer capacity for abstract thought and is more future-focused, so that discussion of smoking as a long-term health risk might be effective.

Complicating the situation, cognitive and emotional capacities may develop at a different pace than physical capacities. Families may be attuned to a child’s emotional or cognitive age, but in social environments, physical appearance becomes the most common guide to frame interactions with a child. Children who mature physically before maturing cognitively and emotionally are at risk of being exposed to information beyond their capacity to comprehend. Community-based public health programs may have a limited ability to attend to the nuance between physical and cognitive/emotional development.

School-based education about sexual and reproductive health has been a flashpoint for a challenge between family values and public health goals. Some of the reported benefits of comprehensive sex education include pregnancy avoidance, increased condom use, delay in initiation of sex, and increased monogamy (Advocates for Youth, 2009). However, some families and communities have rejected these health promotion efforts as contrary to religious or other closely held views about sexuality and reproduction. Families argue, from the stewardship perspective, that their duties and rights as stewards of their children’s moral development limit the schools’ right to present a curriculum around sexuality, challenging the ethical justifiability of sex education programs.

With any public health activity, the ethical justification depends on several considerations, including the importance of the public health problem, the likelihood that this activity will meet the goal of reducing the problem, the burden the program places on the community or the individual, and whether less burdensome alternatives are available (Kass, 2001; Upshur, 2002; Childress et al., 2002). School-based sex education in the United States illustrates the challenges presented by public health programming for the school-aged child and adolescent. Specifically, it illustrates how the ethical justifiability of a public health program can be challenged. There has been little debate about the importance of the problem of high-risk sexual behavior and unwanted pregnancy. However, debates about the use of school-based sex education as part of a public health program to promote safer sex have been vigorous. In the United States, the debates have focused predominantly on two considerations related to ethical justification: the effectiveness of sex education programs, and whether sex education encourages early initiation of sexual behavior or high-risk sexual behavior. Although federal funding was, for many years, limited to abstinence-only education, detractors cited scant evidence of effectiveness (Kirby, 2008). Without evidence of effectiveness, abstinence-only programs are hard to justify.

Even without evidence of harm from abstinence-only programs, their ineffectiveness implies a lost opportunity to meet the public health goal and misdirection of limited (p. 199) public health resources. Comprehensive sex education, on the other hand, has been shown to increase knowledge and change behavior, but detractors have continued to raise concerns that comprehensive sex education promotes early sexual activity. If evidence of that harm ever materialized, it would create a strong argument that comprehensive school-based sex education creates an undue risk or burden to the community and was unjustifiable as a public health program.

In addition to beliefs about sexual morality, a key component of the concern about promotion of sexual behavior has been the appropriate target age for sex education. While sex education is most effective when introduced in early adolescence, the variability in cognitive and emotional capacities of early adolescents has generated concerns that sex education might have the unintended consequence of encouraging sexual behavior in cognitively or emotionally young teens.

Although there has not been any evidence that school-based sex education encourages sexual activity among young adolescents, the concern that health promotion activities might have harmful unanticipated consequences for children and adolescents is very real. Obesity has become a serious threat to public health, and obesity prevention is on the agenda of many governments. Health promotion messages about obesity must be carefully gauged to avoid creating a second burden of anxiety, shame, or even disordered eating for children who are overweight or obese (Toftemo, Glavin, and Lagerlov, 2013; Salas, 2015). Similarly, sexual assault prevention messages have been criticized as blaming the victims for failing to be in control, and sexually transmitted disease prevention messages have raised concerns about increasing stigma to the extent that adolescents will not seek care. In each of these cases, ethical justification for the program rests in large part on ensuring that any risks of the messaging, particularly those related to the cognitive and emotional vulnerabilities of children and adolescents, are carefully considered and addressed.

Access to Confidential Health Services for Adolescents

Children and adolescents typically rely on parents or other caretaking adults for access to health care when access requires financial payment or insurance. When access to care or specific treatment requires informed consent, children and adolescents are, with few exceptions, legally prevented from authorizing care and are usually presumed to be incapable of fully informed consent. An important practical tension arises when adolescents limit their use of necessary or beneficial care due to a concern for confidentiality. Public health programs that provide confidential reproductive health care to adolescents, for example, are designed to reduce disease transmission and unwanted pregnancy by removing obstacles that might dissuade an adolescent from seeking reproductive health care. Decades of evidence confirm that adolescents are more likely to seek care for reproductive health when confidentiality is offered (Carroll et al., 2012; Cheng et al., 1993). Confidentiality has been seen as instrumental in achieving the public health goal of optimizing access to reproductive health care for adolescents.

(p. 200) An ethical tension in access to health care arises from conflicting duties to ensure that adolescents have access to necessary care while respecting the family’s interest in being informed about health risks to which the adolescent is exposed and treatments an adolescent might undergo. In this arena, confidentiality for adolescent patients has both intrinsic and instrumental value. One of the central principles of biomedical ethics is the duty to respect autonomy (Beauchamp and Childress, 2013). For pediatric and adolescent patients, the duty to respect autonomy is complicated by the fact that autonomy, as capacity for self-rule, is a developmental construct. As children develop cognitive and emotional capacities, the autonomy-related duty moves from protecting and promoting the developing autonomy of young children toward respecting the decisions made by adolescents who have decision-making capacity similar to that of adults. As an intrinsic value, protection of confidentiality for adolescent patients is a commitment to respect the autonomy and the dignity of people who are in need of care. The duty is limited by the actual capacity for decision-making, but the presumption that adolescents and older children lack capacity is unrealistic.

As an instrumental value, the promise of confidential care increases the likelihood that adolescent patients will seek care and offer frank disclosures of health concerns. Both values, intrinsic and instrumental, are important in the care of adolescents, who, from a developmental perspective, are seeking to achieve autonomy from their parents and are learning to make appropriate decisions about a variety of issues, including healthy behaviors and seeking health care.

The challenge in adolescent reproductive health care is to balance these intrinsic and instrumental values of confidentiality with the duties to promote adolescents’ well-being and avoid harms. While adolescents are developmentally programmed to seek independence, families remain, in most situations, their primary source of moral and financial support and protection. Programs offering confidential care should seek to enrich family connections while encouraging healthy independence. Communities and families can be engaged in program planning and implementation so that the rationale for confidential care is clear and the limits of confidentiality—specifically related to disclosure of high-risk behavior—are established and accepted.

Failures of Stewardship

Children and adolescents suffer avoidable harms when parents or legislative groups, as stewards of children, obstruct access, fail to protect access, or fail to promote access to highly valuable care. Vaccination against common infectious diseases is a current example. Childhood immunization has been one of the most significant public health successes of the modern era. Immunization programs meet all criteria for an ethically justifiable public health program. In recent decades, however, vaccine refusal has rendered large populations of children (and others in the community, such as the immunocompromised) vulnerable to highly preventable disease. The best available scientific evidence does not support vaccine refusal. Stewardship requires the capacity and willingness to (p. 201) protect the child against irrevocable and avoidable harms. In the vaccination case, government policies can exacerbate failures of parental stewardship (Omer et al., 2006). Vaccine refusal is most common in states or jurisdictions where public health policies routinely grant nonmedical exemptions, such as religious or philosophical exemptions, to immunization requirements for school admission. Similarly, policies that allow religious exemptions from medical neglect statutes allow parents to reject effective medical care for their children without legal repercussions. This can result in limited access to necessary care for vulnerable children and adolescents (Antommaria and AAP Committee on Bioethics, 2013).

Global morbidity and mortality data highlight specific failures in the stewardship duties of political systems. Mental health concerns, for example, particularly depression, are a major cause of morbidity and mortality for children and adolescents. However, access to mental health services is inadequate, hampered by government policies and inadequate funding (Kieling et al., 2011). Interpersonal violence has held a spot in the most prominent causes of death in adolescents for decades, but gun control and even research into firearm injuries fails to clear political obstacles in the United States. These and other public health concerns of particular relevance to children and adolescents should be comprehensively addressed to reduce the burden on disease on this population. In addition, epidemiological data now identify the population-level risk factors for childhood health disparities that could be addressed early to promote lifelong health and well-being, both in this population and in society more broadly. Stewardship, informed by principles of health equity and the rights of the child, requires policies and practices that not only ensure access to health care, but also address the socioeconomic, environmental, and behavioral determinants of children’s health (AAP, 2010).

Conclusion

Ethical issues in public health approaches to the fascinatingly complex and diverse population of children and adolescents arise from three themes that connect this population: lack of political and economic power, stewardship of parents and the state, and presumption of incapacity. While the Convention on the Rights of the Child seeks to establish the “best interests of the child” as the threshold for ethically justifiable public policy, this standard remains mostly aspirational. Children do not vote and do not hold much, if any, financial or political power, so their interests require the protection of other, self-interested, parties. A “good enough interests” standard, as a pragmatic compromise of aspirations, liberal theory, and political reality, comports with a stewardship model of parenting and state action in the lives of children.

Stewardship is as beneficial as the steward is capable, willing, and free to steward. But disparities within and between societies are profound. The legal presumption of incapacity flies in the face of the logic of child and adolescent cognitive and emotional (p. 202) development. Public health policies and practices can support children and adolescents at these critical periods along the health trajectory by anticipating the risks related to disenfranchisement, advocate for enlightened stewardship within both families and political leadership, and promote respect for developing capacity and autonomy.

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