So I'm going to initiate this by writing the first post. A couple months ago I came across an intriguing article* that discusses the intersection between pediatrics, public health, and human rights. It mentions some great and valid points, but I'm not too sure I agree with them on every point.

The article essentially asks what are the criteria to allow prophylactic interventions to be done on children, "in their best interest" and/or for public health reasons. Children can be considered a "special population" in that they have little/no voice for themselves and are thus very vulnerable. Parents provide proxy consent until they reach the age of majority (teen years) but does that mean parents and health care workers should have near-complete power over their health decisions until then? Four cases are examined and they can be broken down broadly into routine immunization and prophylactic and/or cosmetic surgery. I will not discuss the criteria but I would like to point out the essential difference between routine immunization and prophylactic/cosmetic surgery in infants and young children.

-----

Routine immunization protects individuals from contracting highly communicable diseases. In addition, routine immunization helps to protect the public from these highly communicable diseases by limiting their spread through "herd immunity." In ideal cases the pathogen may be eradicated through routine immunization, as in the example of smallpox.

Broadly speaking, routine immunization is most often done in infants and young children, as they are most at risk for these communicable diseases and they are also most likely to suffer severe complications from these diseases. Routine immunization is minimally invasive and the key point is: the child is given something - immunity - and nothing is taken away. Overall there is a net gain with routine immunization in general. However, the rare but serious side effects that can occur as a result of immunization cannot be discounted. The more complex question is, what about immunizations for diseases that either have a low morbidity/mortality or are not so highly communicable? Examples such as chickenpox, Hepatitis B, and HPV vaccinations come to mind.

With chickenpox, the disease is rarely serious in children and mostly just an annoyance. But in adults who did not get chickenpox (or only got a very mild case of it) as children, they are at risk for developing shingles from the pathogen that causes chickenpox in children; shingles can easily be very serious and life-threatening. With chickenpox there is this gray zone. It can be argued that the chickenpox vaccine is unnecessary in children, but if a child reaches adulthood and never caught chickenpox, then he/she should be vaccinated as an adult. And by this time the person can give his/her consent.

Hepatitis B (HBV) is often transmitted via blood or sexual contact. As such most people are generally at very low risk of contacting HBV provided they practice safe sex as an adult (something everyone should do anyway) and children are at almost zero risk for contracting HBV. Certain populations - such as intravenous drug users and prostitutes - are at high risk for contracting HBV. There is also a particular risk to health care workers due to possibility of needle sticks with HBV-infected blood. The question is then, why give children routine immunization against HBV when it's possible to wait until their teen years when they can give consent themselves?

HPV, the virus that causes genital warts, cervical cancer in women, implicated in penile cancer in men (though this cancer is exceedingly rare anyhow), and implicated in anal cancer in both genders, is transmitted through sexual contact only. Currently a 3-dose vaccination is given to girls between 11- and 13-years-old, generally before (hopefully) these girls become sexually active. This vaccination is curious because it borders on the age when these girls can give their own consent independent of the parental proxy consent. This presents its own unique ethical issues.

Gray areas aside, there is general agreement that routine immunization overall is a good idea. There may be a few vaccines here and there that potentially present ethical dilemmas, but for the rest there is really not much to argue. A more critical appraisal of routine immunization may be examined in a later post.

-----

In contrast to routine immunization, prophylactic/cosmetic surgery in children, particularly infants, are far more controversial. The idea of prophylactic surgery is to remove tissue in the hopes of preventing or at least reducing the risk of a particular disease(s). With cosmetic surgery (separate from reconstructive surgery due to a malformation like cleft palate), it is done to help a child "fit in" or for some other reason given by the parent(s). The article presents strong arguments against any prophylactic or cosmetic surgeries in infants or young children.

An example of a highly controversial prophylactic surgery is neonatal mastectomy (removal of the breast tissue) for girls with a strong family history of breast cancer and may have tested positive for a BRCA1/2 gene mutation (though such genetic testing in children presents ethical issues of its own). Note: neonatal mastectomy is not standard or common practice, and I have no knowledge of it actually being performed anywhere in medicine. About 1 in 8 (12.6%) US women get breast cancer each year. For women who test positive for a BRCA1/2 gene mutation, their personal risk jumps to approximately between 50% and 80% chance of developing breast cancer. Prophylactic mastectomy greatly reduces the possibility of developing breast cancer (as you can't get cancer of something you no longer have). If these women were identified to carry a BRCA1/2 cancer-causing gene mutation as infants, would it be ethical to prophylactically remove their breast tissue as infants?

In general the resounding answer is: NO. Any surgery - however major or minor - has attendant risks and complications (direct or indirect). Furthermore, any surgery has the possibility of maiming or mutilating the individual. While (prophylactic) surgery may prevent or reduce one's risk of a given disease(s), there are almost always more conservative routes of prevention. If it is not immediately medically necessary, there should be no reason to remove/alter any part of the body - especially in individuals who cannot give their expressed consent. It can be argued that parental proxy consent is "not strong enough" to override the rights of the child to his/her bodily integrity, even if the parents believe the surgery to be done "in the best interest" of the child.

Cosmetic surgery is (should be) less acceptable by any medical or public health criteria. There is often (if not always) no health benefit to the individual. An example the article gives is cosmetic ear surgery to correct "bat ears" in children. One cannot say that the surgery will go well (even if it has a very high success rate and/or low complication rate), one cannot defininitively determine the future development of the child, and one cannot predict the emotional state of the child. While surgical correction of "bat ears" sounds ludicrous to many individuals, it is of genuine concern to some parents to make sure their child has "normal" ears to fit in.

In contrast to routine immunization, prophylactic/cosmetic surgery should not even be considered in infants and young children except in cases of immediate medical necessity. Unlike a vaccination, something must be removed in hopes of providing a net benefit that may never be realized - there is initially a net loss before a net gain (if any) can be attained; and unlike a vaccination, all surgeries are invasive. Furthermore, there are almost always more conservative routes of prevention until the individual reaches the age of majority and can give his/her own consent. As the US Centers for Disease Control (CDC) and the American Academy of Pediatrics (AAP) revise some of their guidelines at the end of this year, it would be wise for them to remember that prophylactic/cosmetic surgery in children is never a good idea and should not be endorsed.

-----

* Article:

Hodges, F.M.; Svoboda, J.S.; Van Howe, R.S. (2002) Prophylactic interventions on children: balancing human rights with public health. Journal of Medical Ethics. 28, 10-16.