A baby boy was born to a mother who is hepatitis B surface antigen positive but e antigen negative (Fig. 1). This means she is a chronic carrier but her disease is relatively inactive, and she is not in the highest risk category for transmission to her baby (if she was e antigen positive the risk of mother-to-child transmission without intervention is 70–90%).1 The parents declined hepatitis B vaccine and immunoglobulin for their baby. I was asked by the neonatologist involved for advice about risk. A review of the limited literature suggested that the risk of mother-to-child transmission of hepatitis B without intervention for this baby was about 10% with wide confidence intervals.1,2 The parents were given this information and told an infected baby would become a chronic carrier and have about a 30% risk of developing liver cancer or cirrhosis later.1 Timely administration of hepatitis B vaccine and immunoglobulin would reduce the transmission risk by over 90% to an absolute risk below 1%.1 Despite being counselled strongly, the parents refused immunisation, citing concerns about aluminium in the vaccine. It emerged that they had a previous child, born at home, who against medical advice never received hepatitis B vaccine. At this point, it was clear that persuasion was doomed and time was of the essence, so we notified the relevant Child Protection authorities that the baby was at risk of developing vaccine-preventable hepatitis B. Child Protection applied to the Supreme Court for permission to immunise the baby against the parents' wishes. The Court decided the baby's right to be protected against a lethal disease conflicted with the parents' right to decide about immunisation and, in this particular case, the baby's right was paramount. A Court Order made the baby a Ward of Court, giving child protection authorities the power to immunise the baby and return him to his parents.
The parents went on the run, evading child protection staff, making frequent phone calls to the media, and involving an anti-immunisation lobby group. The lobby group tried to use the situation to accuse the Health Department of riding rough-shod and illegally over parents' rights. However, this completely ignores the baby's rights.
In general, parents have the right to decide about their children's medical care and to decline health-care interventions. This is appropriate, because parents can usually be relied upon to make good decisions about their own children's health care and because parents have to live with the results of any decision. In Australia, parents have the right to choose whether or not their child is immunised. Over 92% of Australian children are fully immunised, enough to protect those few children whose parents refuse immunisation or have contraindications. For an individual Australian baby, the risk of immunisation is negligible but the risks of infection are fairly low, and parents decide.
In several countries and in many US states, childhood immunisation is compulsory, with a range of sanctions for non-compliance. In Australia, persuasion is preferred to coercion and very high levels are achieved without sanctions. It can be argued that parents are more likely to value non-compulsory immunisation, although advocates of compulsory immunisation disagree. I prefer the Australian approach, at least while high levels of immunisation can be maintained. In my opinion, it is better to live in the sort of country that asks people to think for themselves rather than tells them what to think.
The said discussion about the relative risks and benefits of childhood immunisation refers to the population at large. The real issue for the baby of the hepatitis B carrier mother was not compulsory immunisation but child protection. If a baby of Jehovah's Witness parents was bleeding significantly, health-care professionals and the courts would mandate blood transfusion, on the ethical principle that the baby was too young to decide and should be allowed to grow up healthy to decide for themselves about such issues. Similarly, the baby of a hepatitis B carrier mother may grow up and choose to be immunised or not, but if he or she already has chronic hepatitis B, the decision has been taken out of the child's hands. The child's right to be protected until old enough to choose is in conflict with the parents' right to choose about immunisation. In complex situations, child health professionals should always consider if they need to advocate for a child's rights.