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Table 2 Ethical values/principles

From: Children as an afterthought during COVID-19: defining a child-inclusive ethical framework for pandemic policymaking

Value/principle

Our revision

Related CRC Article(s)

Duty to provide care

Conceptualizations of ‘good’ care need to be rooted in strong conceptualizations of best interests and agency that position young people as agents with rights. In particular, care in a pandemic needs to equally consider the young person and their capacities in the ‘here-and-now’ and their ‘future’ capacities, along with the ways in which children are interrelated with those around them. Caring for young people requires that we care for those who support them too.

In addition, care should extend beyond the health sphere and acknowledge that public health policies have impacts on many other sectors, especially for children, such as education, social supports, child welfare, etc. Engaging with teachers, parents or others to establish practice guidelines that work for their particular settings or spaces is one way that care can be extended during a public health emergency.

Young people should also be involved in defining what types of care they need and how the tools for care provision can align with public health goals.

Article 3: Best Interests of the Child

Article 6: Life Survival and Development

Article 9: Keeping Families Together

Article 12: Respect for Children’s Views

Article 13: Sharing Thoughts Freely

Article 19: Protection from Violence

Article 22: Refugee Children

Article 25: Review of a Child’s Placement

Article 26: Social and Economic Help

Article 28: Access to Education

Article 30: Minority Culture, Language and Religion

Article 32: Protection from Harmful Work

Article 34: Protection from Sexual Abuse

Article 36: Protection from Exploitation

Equity

Social determinants of health ought to play a role in pandemic decision-making. There needs to be a place for long-term impacts to be included within pandemic plans and a fulsome examination of the way children's lives and rights will be impacted by pandemic decisions (and how particular children's rights, such as rights to education, may be impacted more than others by decisions made). Emphasizing the fundamental right young people have to access and receive healthcare is crucial in this context.

In addition, several groups of children have experienced heightened familial and individual burden and harm, as a result of the pandemic, that have been overlooked and not rectified. To note, many of these impacts have existed before the pandemic and have been heightened in the current context, and the impacts amongst these groups are not identical.

Article 2: No Discrimination

Article 3: Best Interests of the Child

Article 30: Minority Culture, Language and Religion

Individual Liberty

Shifting to more relational models of liberty and autonomy is necessary, as these concepts are seen as better visions of autonomy and individual liberty for young people, considering the fundamental social relations that structure their lives.

Pragmatically, this may mean acknowledging times when restrictions are necessary but not sufficient for supporting a young person accessing care by recognizing the crucial role for parents, caregivers, and family in caring for young people during a pandemic. Ideally, interdisciplinary teams will be created to support young people and families with decisions, wherein the young person is still able to contribute to deliberations on matters that impact them and where tools (like art or surveys) are used to facilitate conversation and knowledge-sharing.

Article 3: Best Interests of the Child

Article 5: Family Guidance as Children Develop

Privacy

In light of young people’s immersion in the digital wave, the definition of privacy must capture the need to protect youth in online forums (i.e., on Zoom, on social media, etc.), as they frequently access these spaces.

Relational views of children need to be used to contribute to understandings of privacy, whereby young people “have their own ethical interests” that have impacts on how their best interests are interpreted, but also acknowledging that young people are “embedded within sociocultural networks of morally-significant relationships” that make confidentiality and privacy complex [56p. e10]. Decision-makers must recognize the capacities of young people and their rights to privacy, while simultaneously acknowledging the protective responsibilities of parents or caregivers. For instance, young people may not want parents to be informed of decisions they make regarding choosing to be vaccinated; a balanced and collaborative approach that ensures parents are informed of urgent needs of children, while children’s rights to privacy are also ensured, is necessary.

Article 3: Best Interests of the Child

Article 8: Identity

Article 16: Protection of Privacy

Proportionality

Young people have faced disproportionate impacts due to COVID-19 as their current and future concerns have not been carefully attended to and the pandemic precautionary measures have unintentionally caused some problematic effects for young people.

To prevent or mitigate these harms, decision-makers must consider that young people face different types of harms than adults and harms that may not have an immediate impact. Children’s rights (to education, to play, to be protected from harm, etc.) ought to be protected to the greatest degree possible or restricted to the least degree possible. Finally, acknowledging that there should be a balance between upholding the interests and rights of young people while having necessary restrictions in place, whereby young people’s needs are not treated as secondary to adults, is a way to ensure proportionality for the young population.

Article 3: Best Interests of the Child

Protection of the Public from Harm

Children have tended to face post-pandemic impacts in previous pandemics, and there are risks of this with the COVID-19 pandemic too. One study from 2013 indicated that living through a pandemic had serious mental health impacts on children, and these impactst arose after the pandemic ended, such that nearly one-third of children who experienced isolation or quarantine had symptoms that met the overall threshold for post-traumatic stress disorder [64]. Adults may face different levels of harm from certain policies compared to young people and this must be weighed when considering what harms we want to protect the public from and how to adapt for a pediatric setting; here, proportionality again becomes valuable to consider.

Children also have rights to protection from harm and there are instances where these have not been abided by. Shifts to acknowledge and mitigate these other harms, through policy and practice, is necessary. Marginalized individuals and communities must be centered in these decisions, to ensure they are protected from the additional harms they face.

Article 3: Best Interests of the Child

Article 9: Keeping Families Together

Article 19: Protection from Violence

Article 20: Children without Families

Article 22: Refugee Children

Article 25: Review of a Child’s Placement

Article 27: Food, Clothing, a Safe Home

Reciprocity

When we consider impacts outside of transmission concerns, we recognize that children of all ages have faced and will continue to face disproportionate burden for the sake of protecting public interests and the lives of their families, friends, and loved ones, and these burdens arise in different forms. It is essential for decision-makers to keep this in mind when developing additional measures of pandemic response, both during active outbreak/community transmission and following the pandemic.

It is necessary to support parents/caregivers too, since children need these individuals to have their interests realized. For example, employing paid sick-leave for parents, families, and youth working in essential jobs and in low socioeconomic positions is one step to ensuring that their current needs are met and for a response driven by reciprocity. Providing preemptive strategies of how children and their family’s economic, social, political, psychological, and physical burdens will be rectified during the pandemic and beyond is essential. Young people should be seen as partners in these conversations.

Article 3: Best Interests of the Child

Article 9: Keeping Families Together

Article 12: Respect for Children’s Views

Article 13: Sharing Thoughts Freely

Article 15: Setting Up or Joining Groups

Article 18: Responsibility of Parents

Article 19: Protection from Violence

Article 24: Health, water, food, environment

Article 31: Rest, Play, Culture, Arts

Solidarity

Efforts must be taken to ensure solidarity exists between decision-makers, clinicians, parents, and children too. In addition, child refugees and families in lower socioeconomic positions faced a heavy burden due to pandemic decisions, so including their experiences in pandemic decisions, through regional and global solidarity with these experiences, is important [77].

There must also be solidarity with the losses that young people have faced as a collective, particularly infringements on their rights as children. These rights must be treated as legally binding commitments rather than a form of ‘pity’ or ‘charity’ [27]. Young people can also help to promote solidarity in their communities, nationally, and internationally.

Article 3: Best Interests of the Child

Article 12: Respect for Children’s Views

Article 13: Sharing Thoughts Freely

Stewardship

Stewardship requires the particular needs of young people to be carefully considered, so that appropriate resources can be reserved for these needs. This is important as reports have indicated a large decrease in number of parents/children attending hospital for complex chronic conditions and the significant (and crucial) delays in children seeking and receiving diagnoses for their symptoms/illnesses due to COVID-19 [78]. It will be the responsibility of institutions and governments to manage resources, and this needs to be integrated with pediatric care too. Those responsible for managing resources must also consider what is necessary or valuable for the future and protect those resources, such as human potential and talent

On the other hand, stewardship also requires children’s institutions to potentially provide resources for adults to use within a pandemic, in order to protect society at large.

Article 3: Best Interests of the Child

Article 24: Health, water, food, environment

Article 26: Social and Economic Help

Trust

Developing trust with young people may require different methods. It involves establishing trust regarding public health decisions that are made and this, inherently, requires the provision of information and communications that are young-person focused and informed. Different methods for building trust may include developing effective and individualized strategies to determine who, in a particular group of young people, can speak on behalf of the group without trivializing the voices of the population. Once these individuals are identified, shared governance or co-governance models must be established, in order for ‘adult leaders’ to ensure that young contributors feel supported, heard, and able to trust the adult partners. This process needs to start early, just as it does with adults, and relies on the use of consistency in public messaging. Learning from established Youth Advisory Councils/Committees is one way to optimize these approaches.

At the same time, just as adults have the right to freely hold their own beliefs, young people too should be granted the rights to their beliefs. Establishing trust means accepting the possibility that these beliefs may not align with public health interests—though efforts should continually be made to keep young people up-to-date on the most current evidence, answer their questions, and inform young people of the consequences of their decisions.

Public trust must be built over time and requires engagement with behavioural science specialists to ensure pandemic responses are fundamentally activities that promote trust [79], especially with young people

Article 3: Best Interests of the Child

Article 12: Respect for Children’s Views

Article 13: Sharing Thoughts Freely

Article 14: Freedom of Thought and Religion

Article 17: Access to Information

Practicability

[Im]Practicability lies between [im]possibility (i.e., whether we can do something) and [im]practicality (whether a thing is useful to do). It is a way of understanding the feasibility of something. By determining if something is practicable, you are determining whether it is do-able, even despite how inconvenient it may be, existing resource constraints, etc. In a time where the impacts of the pandemic on young people have been largely overlooked compared to adults and compared to controlling rates of viral transmission, it may be practicable to devote funding to ensuring that young people’s interests are going to be met. However, this may not be practical (in that there are competing demands, diverse interests, an adultcentric society, and the rational need to worry about limiting transmission as a primary concern). As such, a fine balance is required to weigh all options and grant priority to solutions that prioritize minimizing the greatest degree of harms possible and maximizing the goods. Overall, practicability requires decision-makers to:

1. Consider all of the risks and benefits that needs to be balanced and the associated minimum threshold for each risk (whereby exceeding the threshold would mean a disproportionate level of risk would be experienced).

2. Take into account whether it is possible to prioritize a particular action or decision, and whether all pathways towards the aim have been exhausted to determine whether something is possible/impossible.

3. Decision makers would also need to take into account whether it is useful to pursue an action/decision/end and who it may be useful for.

Article 3: Best Interests of the Child