International Journal of Africa Nursing Sciences 14 (2021) 100284

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International Journal of Africa Nursing Sciences

journal homepage: www.elsevier.com/locate/ijans

The recognition of children’s voices in health care and research within

Nigerian child protection legislation: A normative analysis
Shilni J. Liberty *, Franco A. Carnevale
McGill University, Ingram School of Nursing. Montreal, Quebec, Canada

A R T I C L E I N F O A B S T R A C T

Keywords: There is a growing body of knowledge about children as moral agents and their capacity and interest to
Children’s rights participate in healthcare and research discussions/decisions that affect them. Although this has led to some
Discussion, Decision-making research and practice improvements that have better-recognized children’s voices, this trend has not been
Informed consent
globally embraced, especially within Sub-Saharan Africa.
Normative analysis
Voice of the Child
Objective: This study examines and analyzes the rights of children to participate in healthcare and research
discussions and decisions within the normative discourse of child protection laws in Nigeria.
Method: We conducted a normative documentary analysis based on five of the principal Nigerian child protection
legislative documents enacted from 1999 to 2019.
Results: Findings demonstrated that Nigerian legislation acknowledges the participation rights of children in
healthcare and research. However, the normative document also emphasized children’s obligation to the given
privileges in the form of respect to parents/guardians, superiors, and elders.
Conclusion: Norms regulating the rights of children are in existence in Nigeria. Nevertheless, legal guidance to
ethical practice in healthcare have been generalized and has not upheld the idea of dignity and liberty of chil­
dren. We recommend that Nigeria should reconsider the code of ethical practices in the fields of health and
research to give children the participatory authority that could provide active involvement and compliance.

1. Introductions healthcare or research is inadequately applied globally (Adejumo &

Under the prevalent protective model practiced in Nigerian health­
care and some counties considered in this study, adults customarily
stand in the gap to protect the interests of vulnerable children and ad­
olescents. Therefore, decisions regarding their care are commonly made
exclusively by parents or legal guardians and healthcare professionals
(Agu, Obi, Eze, & Okenwa, 2014; Douglas & Walsh, 2010; Folayan et al.,
2015; Bubadué, Cabral, Carnevale, & Asensi, 2017; Carnevale, 1997,
2002, 2008; Glass & Carnevale, 2006). Nevertheless, national and in­
ternational studies have progressively suggested the importance of
involving children in their healthcare and research (Agu et al., 2014;
Bubadué et al., 2017; Carnevale & Manjavidze, 2016; Cashmore &
neglect, 2002; Coyne, Amory, Kiernan, & Gibson, 2014; Coyne & Gal­
lagher, 2011). These recommendations are not practiced, which results
in children and adolescents often silenced with regards to exercising
their rights. They are seldom allowed to express their views on issues
related to their health care and research (Agu et al., 2014; Adejumo &
Adejumo, 2009; Bubadué et al., 2017). Similarly, their participation in
Adejumo, 2009; Adi, Abdu, Khan, Rashid, Ebri, Cockcroft, & Andersson,
2015; Agu et al., 2014; Akinwumi, 2010; Coyne, 2008; Gilljam,
Arvidsson, Nygren, & Svedberg, 2016).
In Nigeria, children are commonly silenced from participating in
discussions and decisions regarding their healthcare, as enshrined in the
country’s laws. Often children are treated as passive rather than active
participants in health-related issues that concern them (Adejumo &
Adejumo, 2009; Agu et al., 2014). According to the Child’s Right Act
Section 19, Article 2a of the Nigerian Child’s Right Act No. 26, 2003, ‘a
child is subject to respect his or her parents, superiors and elders at all
times…’ (Nigerian Child’s Rights Act No. 26, 2003). This wording im­
plies that the child must, at all times, consider and follow decisions made
by adults without dissent. For instance, situations such as invasive and
non-invasive medical procedures, duration and nature of the treatment.
There are cases where children in other countries, such as Canada and
Australia, have been encouraged to express their preference according to
knowledge and options available (Cashmore & neglect, 2002; Coyne,
2008; Ruiz-Casares, Collins, Tisdall, & Grover, 2017; Grace et al., 2019;

* Corresponding author.
E-mail addresses: shilnipukuma@gmail.com (S.J. Liberty), franco.carnevale@mcgill.ca (F.A. Carnevale).

https://doi.org/10.1016/j.ijans.2021.100284
Received 30 January 2020; Received in revised form 18 November 2020; Accepted 14 January 2021
Available online 19 January 2021
2214-1391/© 2021 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
S.J. Liberty and F.A. Carnevale
Marsh, Mwangome, Jao, Wright, Molyneux, & Davies, 2019). However,
such has not been the practice in Nigerian healthcare or research as
children are subject to whatever decision taken on their behalf by par­
ents, guardian or healthcare professionals (Adejumo & Adejumo, 2009;
Adi et al., 2015; Agu et al., 2014; Akinwumi, 2010). Examples of this
include the alleged involvement of nurses in the unethical treatment of
children recruited in Pfizer’s clinical trial of Trovan for cerebrospinal
meningitis in northern Nigeria (Adejumo & Adejumo, 2009). According
to Adejumo & Adejumo (2009), nurses, patients and their families were
not given sufficient information to accord ethical decision making which
resulted to lawsuit between the families and Pfizer company. Also, a
study conducted to examine the attitudes of people towards informed
consent in developing countries indicated that the educational level of
individuals affects their views regarding informed consent with chil­
dren. Approximately 70% of those who had tertiary education noted
that informed consent was necessary for procedures on children, while
the more significant number of those with primary (64.4%) and no
formal education (76.4%) indicated that informed consent was not
necessary for procedures on children (Agu et al., 2014)
Furthermore, Nigeria makes health care decisions on children based
on the Nigerian Child’s Rights Act: “the best interest of the child as the
paramount consideration in all action,” (Section 1 Article 1) and “to give
protection and care necessary for his or her well-being” (Section 2 Article 1
and 2). Section 19, Article 1 and 2 of the Nigerian Child’s Rights Act No.
26 2003 state that: “Every child has responsibilities towards his family and
society, the Federal Republic of Nigeria and other legally recognized com­
munities, nationally and internationally” therefore, “A child shall in the
subject to his age and ability and such other limitations as may be contained
in this Act and any other law, to (a) work towards the cohesion of his family
and community; (b) respect his parents, superiors, and elders at all times and
assist them in case of need (Nigerian Child’s Rights Act No. 26, 2003). As
declared by the law, the adult’s judgement determines the best interest
of the child as further explained in Section 19, Article 1 and 2 of the
Nigerian Child’s Right Act No. 26 2003. Although these legal codes
protect children, in the same vein, it silences them, especially in an
instance where they may need to have their voices heard in the pro­
motion of their quality of life and healthcare.
Emerging studies on children’s health have revealed that the voices
of children can be relevant in health-related discussions and decision-
making, especially those relating to them. Stressed by these studies,
such practices will help them develop self-confidence, reduce fear,
improve adherence to treatment and recognize their agency (Coyne,
2008; Grace et al., 2019; Marsh et al., 2019; Bubadué et al., 2017;
Carnevale, 2012; Committee on Bioethics, 2016; Gaudreault & Carne­
vale, 2012). Some African countries, such as Ghana, South Africa,
Tanzania, including Nigeria, have made efforts to revamp the medical
system. They established a universal health care system where chil­
dren’s rights would be protected by law and recognize children’s voices,
but none of the mentioned countries have yet achieved (Ajayi & Dibosa-
Osadolor, 2013; Adegbehingbe, Oginni, Ogundele, Ariyibi, Abiola, &
Ojo, 2010; Amodu, Olumese, Gbadegesin, Ayoola, & Adeyemo, 2006;
Renne, 2010).
Countries with universal health care systems such as Canada and
Australia, have recognized the voices of children in healthcare practice
irrespective of social class, sex, age, or race (Coyne, Amory, Gibson, &
Kiernan, 2016; Montreuil & Carnevale, 2016). Pediatric healthcare
professionals often encounter moral and ethical problems that require
legal/court intervention (Coyne & Gallagher, 2011; Cureton & Silvers,
2017; Francis & Silvers, 2013; Koller, 2017; Marsh et al., 2019; Mer­
curio, Murray, & Gross, 2014). Health policies, programs, and materials
provided by the countries named above have been instrumental in
overseeing the protection of the rights of the child as well as their in­
clusion in health decisions according to the child’s capacities (Cash­
more, 2002; 2017;; Canada Department of National & Welfare, 1981;
Federal-Provincial Working Group on & Family Services, 1994). These
have acknowledged the voices of children and enhanced the quality of
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International Journal of Africa Nursing Sciences 14 (2021) 100284
healthcare practices with children.
For instance, Australia has integrated children in discussions and
decision-making regarding healthcare and protection within its legisla­
tion. For example, in Queensland, a ‘Charter of Rights for Child in Care’
is included in the Child Protection Act 1999, New South Wales (NSW)
(Cashmore & Neglect, 2002). Similarly, in Canada, the voice of the child
in healthcare decision-making that relates to them has been recognized
with age considerations (Canada Department of National & Welfare,
1981; Federal-Provincial Working Group on & Family Services, 1994;
Ruiz-Casares et al., 2017). Both in Canada and Australia, policies pro­
mote child inclusion in healthcare discussions and decisions. Note­
worthy children’s capacity to participate has also been regulated both
legally and ethically.
In contrast, since 2003, Nigeria has passed a bill to protect the rights
of children but has failed to implement the Act nationally. According to
research reports by Olayinka (2010) and Daniel (2018), only nineteen
States out of the thirty-six states in the country support the legal pro­
tection of the rights of the child. Efforts to adopt the Child’s Rights Act
nationally have not been successful because of political, socio-cultural,
and religious considerations (Olayinka, 2010; Daniel, 2018).
The Nigerian Child’s Right Act 2003 provides guidelines for all
professional codes of conduct involving Nigerian children. Hence, a
normative analysis of Nigerian laws and standards seemed warranted at
this time, shedding light on the state of children’s rights while pro­
moting the protection of children in healthcare practices. Healthcare
practices were considered an essential focus for this study because of
their importance in protection, promotion, and improvement of chil­
dren’s quality of life. A second reason for this inquiry is grounded in a
review of the existing literature, which identified knowledge gaps
regarding existing norms on the rights of children in healthcare and
research in Nigeria. These gaps exist in Sub-Saharan Africa as well, but
we have narrowed the focus of this article solely on Nigeria.
This article examines the recognition of children’s voices – or not - in
healthcare and research discussions and decision-making that pertains
to them, through a normative analysis of child protection laws in
Nigeria. With a focus on normative and regulatory child protection
documents, the authors assayed children’s participation in healthcare
practices, given understanding the limitations and strengths of the laws
and regulations guiding pediatric practices. Through this investigation,
we aim to assess whether these normative standards adequately support
the participation of children in discussions and decision-making in
healthcare and research in Nigeria.
1.1. Research objectives
To examine and analyze the voices of children in healthcare and
research through a normative discourse analysis of child protection laws
in Nigeria.
1.2. Research questions
Are children entitled to any participation rights in healthcare and
research within child protection laws in Nigeria?
2. Methods
In health research, normative analysis is yet to be popular. However,
a few studies have postulated on its significance and adaptation
(Bubadué et al., 2017; Omura, Stone, Maguire, & Levett-Jones, 2018;
Zanotti & Chiffi, 2016). An example of a normative study considered in
the present work undertaken in Brazil studied contextually the legal
conduct applied to children’s participation in health care and research.
The normative analysis prescribed for normative child protection trea­
tise to grant children a voice, though with restrictions and operates
under the authority of an adult or parental authority (Bubadué et al.,
2017). The second study examined was a research work that investigates
S.J. Liberty and F.A. Carnevale
behavioral and control beliefs concerning assertive communication
among Japanese nurses in a pediatric department. A normative analysis
was used together with other studies to explore the number and type of
expressions applied by children to express pain. Normative analysis
specified the importance of understanding the child’s self-reported pain
based on the child’s ability to relate (Omura et al., 2018).
The present article involves a documentary analysis of legislative
norms that guide the practices of health professionals in healthcare and
research in Nigeria. The primary data utilized in the report were
considered according to the relevance of the preliminary data from
normative documents that relate to the Nigerian child protection legis­
lation. A content analysis approach was used to examine the documents,
and Baron’s normative analysis method for ‘normative models of judg­
ment and decision making’ (as described in Blackwell Handbook of
Judgment and Decision Making) was used for understanding and
interpretation of the documents (Koehler & Harvey, 2004).
National and health databases were explored to identify relevant
literature for this article. Searches included the terms “rights, children,
law, act, code of ethical conduct, discussion, decision-making, informed
consent, normative analysis, the voice of the child.” To ensure
comprehensiveness, we searched for synonyms of keywords, “legisla­
tion, code of ethical practice, privilege.” Databases examined involved:
Scopus, CINAHL, Pubmed, and Google Scholar. Results were limited to
Nigerian legislation, national code of ethical conduct for healthcare
professionals, and health research documents within 1999–2019. The
review of documents - the pre-analysis stage – involved the selection of
national normative documents that address children’s voices within the
papers. Documents were organized to form the basis for analysis uti­
lizing the following principles of content analysis (a) Thoroughness: all
documented sections related to the child’s voice were considered; (b)
Representativeness: documents that addressed children’s participation;
(c) Homogeneity: normative documents that made reference to chil­
dren’s right to active involvement; lastly, (d) Pertinence: the relevance
and ability of normative documents to address the objective of this
analysis. Documents reviewed and selected from national normative
documents were based on the following inclusion criteria: 1) Articles on
children’s rights in healthcare and research, laws, decrees, and resolu­
tions that relate to children as acknowledged by the Nigerian constitu­
tion; and 2) Covering the 1999 to 2019 period. Exclusion criteria
included: 1) Articles on children that did not address the rights of chil­
dren in healthcare or research; and 2) Articles that are neither laws,
decrees, or resolutions and did not cover the 1999 to 2019 period.
The documents considered were used to form the body of analysis.
This resulted in the selection of five documents for inclusion, as pre­
sented in Table 1, and five documents were excluded based on the
criteria considered in the study as mentioned above, as shown in Table 2
below.
Exploration of material-meta-analysis is the second stage, which in­
cludes understanding, interpretation, and inscription of the corpus of the
analysis. The texts were classified into categories to constitute the
description of study attributes, that is, children’s voices as represented
in the texts. The last stage explored the core meaning of the character­
istics of children’s voices. A descriptive model generates a suitable
prescriptive model, which makes up an excellent normative analysis.
Therefore, the researchers explored descriptive articles and prescriptive
articles. The descriptive model expounded the legal documents as pre­
sented in statutory texts and moral principles of the law. At the same
Table 1
Normative texts included in the corpus of analysis. Nigeria 1999 to 2019.
Nigerian Child’s Right Act, No. 26 (NCRA) 2003.
National Code of Health Research Ethics (NCHRE) 2007.
Version 1.0 of the Policy Statement Regarding Enrollment of Children in Research in
Nigeria (PS2.1016) 2016.
Code of Ethics for Nursing and Midwifery Practice Nigeria 2004.
Medical and Dental Council of Nigerian Code of Ethics (2004).
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International Journal of Africa Nursing Sciences 14 (2021) 100284
Table 2
Normative texts excluded from the text corpus of analysis. Nigeria, 1999 to
2019.
Constitution of the Federal Republic of Nigeria 1999
Children and Young People’s Act (CYPA) 1943
The Integrated Maternal, Newborn and Child Health (IMNCH) Strategy of 2007
National Health Act, 2014 Federal Republic of Nigeria.
National Adolescent Health Policy 1995
time, the prescriptive model states how standards and legal principles
should be incorporated into practice. Grounded within this normative
framework, we analyzed texts from documents regarding critical ethical
codes, such as autonomy (dignity, informed consent, and confidenti­
ality) beneficence, non-maleficence and justice (liberty and freedom).
A normative analysis of the law is not an attempt to oppose the
prevailing legal standards but rather an effort to incorporate legal
standards into healthcare practice to protect the rights of healthcare
recipients if possible, in this case, the children. Consequently, normative
analysis is considered suitable for comprehending legislative context
and conduct rather than regulating that which is accepted and followed.
An example can be a prescriptive model of legal conduct applied to
healthcare practice and research with children, where children’s rights
will be incorporated and empowered by law in healthcare and research
with children.
In this article, we used normative analysis to interpret the legal
principles that are justifiable and could form the basis of supporting
children’s participation in healthcare and research.
3. Results
The analysis resulted in two categories and five sub-categories for
each of the two groups. Category 1. the rights of children in healthcare; 1.1.
right to dignity; 1.2. right to information, 1.3 right to protection. 1.4
right to confidentiality 1.5 right to informed consent. Category 2. the
rights of children in scientific research; 2.1. right to dignity 2.2. right to
liberty, 2.3. right to information, 2.4 right to consent; 2.5 right to
confidentiality.
3.1. The rights of the child in healthcare
The Nigerian Child’s Right Act No. 26 2003 provides expected
conduct for every organization in the management of the child. It covers
both governmental, non-governmental institutions or individuals and
provides guidelines to uphold the best interests of the child. Conse­
quentially, it is pertinent that health care professionals and researchers
should seek the best interest of the child as it is the child’s right ac­
cording to the Child’s Rights Act.
“In every action concerning a child, whether undertaken by an individual,
public or private body, institutions or service, court of law, or administrative
or legislative authority, the best interest of the child shall be the primary
consideration,” Section 1 of the Nigerian Child’s Right Act No. 26. (NCRA)
2003
The Nursing and Midwifery Council of Nigeria (2004) stated it
clearly in the code of conduct for Nigerian Nurses and Midwives that
they should provide care without prejudice to age among other clients.
As a result of this rule, the age of children should not deprive them of
acceptable healthcare services.
“Provide care to all members of the public without prejudice to their age,
religion, ethnicity, race, nationality, gender, political inclination, health or
social-economic status,” Nursing and Midwifery Council of Nigeria (NMCN)
2004.
According to the nursing and medical code of practice, the right to
consent to medical or nursing treatment should be ensured by the par­
ents, or legal guardians, in consultation with the most senior in the
healthcare team or the law. Consequently, children in Nigeria are, by
this law, expected to receive healthcare interventions according to the
S.J. Liberty and F.A. Carnevale
consent of an adult.
“Ensure that the client/patient of the legal age of 18 years and above gives
informed consent for Nursing intervention. In case the health consumer is
underaged, the next of kin or the parents can give informed consent on his
behalf the Nursing and Midwifery Council of Nigeria (NMCN) 2004.
Where the patient is underage (below eighteen years (18) by Nigerian
law), or is unconscious, or is in a state of confusion mental impairment, a
next-of-kin should stand-in. In the absence of a next-of-kin, the most senior
doctor in the institution can give an appropriate directive to preserve life. In
special situations, a court order may need to be procured to enable life-saving
procedures to be carried out.” Article 19, Medical and Dental Council of
Nigeria (MDCN) 2004.
Exceptions seem to exist as it relates to the right to consent regarding
a religious belief for or against adherence to treatment according to the
Medical and Dental Council of Nigerian code of conduct 2004. This
statutory guide categorizes at what age a child can consent during a
contradictory religious treatment, but notwithstanding his right, the
parents’ decision takes precedence over that of the child.
“Article 39 Section C subsection (a) those within ages of 16 to 18 years
have a statutory right of their own to consent to procedures, and this takes
precedence over parental objections but does not invalidate the right of others
to consent on their behalf. However, where the child of this age group objects
and parental consent obtained in an emergency, appropriate treatment or
procedure can be given. Section C subsection (ii) children younger than 16
but not below 13, though considered as minors, but of clear mind and can
grasp the benefits and consequences of accepting or rejecting a proposed
treatment, “Gillick-competence,” can give an acceptable consent. Section C
subsection (iii) in respect of children under 13, but the well-being of the child
is paramount. If, after full parental consultation, treatment is refused, the
practitioner should make use of the law by obtaining an order from the court
to protect the child’s health interest. A child who needs blood transfusion or
procedures in an emergency should be so given. A practitioner who stands by
and allows his minor patient to die in circumstances which might be avoidable
may be charged with negligence and is also vulnerable to criminal prosecu­
tion.” Article 39, Medical and Dental Council of Nigeria (MDCN) 2004.
As part of the right to human dignity, this necessitates that the
agency of the child should be recognized. It is pertinent to grant children
the power to express their wishes, views, and opinions in healthcare
discussions and decision-making. Also, children should be confident that
their opinions will be valued and respected. Children should have the
assurance that their conversation is protected and treated ethically.
According to the Nigerian Child’s Right Act No. 26, 2003, the law for­
bids medical professionals from disclosing professional information
shared to them by children. The child is entitled to privacy except where
non-disclosure could cause harm to the child or society. Therefore,
health professionals should be responsible for assuring confidentiality
during therapeutic discussions (The Nigerian Child’s Right Act No. 26
(NRCA) 2003).
“Every child is entitled to his privacy, family life, home, correspondence,
telephone conversation, and telegraphic communication, with the regulation
of the parent.” Section 8 article 1 of the Nigerian Child’s Right Act No. 26
(NCRA) 2003.
Respect for liberty and dignity governed by this Act encompasses the
autonomous right of children to reason and decide on issues that relate
to them without coercion. The child should be free to consent, assent, or
reject an intervention as his or her thoughts and conscience permits, as
stated in the Nigerian Child’s Right Act No. 26. Therefore, health pro­
fessionals ought to respect the choices made by children and give due
recognition to their cognitive ability.
“Every child has the right to freedom of thought, conscience, and
religion.” Section 7 article 1 of the Nigerian Child’s Right Act No. 26
(NCRA) 2003.
One element of the child’s right to dignity falls under the child’s right
to liberty. For example, this would involve the freedom of movement
around after admission within the healthcare facility. Children should
be at liberty to be involved in recreational activities after admitted and
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International Journal of Africa Nursing Sciences 14 (2021) 100284
to receive some form of education to keep them up to date with their
academic work. It is the right of the child to be visited by friends and
family and to choose visitors’ (section 6 of the Nigerian Child’s Right Act
No. 26 2003). Therefore, keeping children for any reason and depriving
the child of their freedom of movement is a form of slavery and violation
of the child’s rights and dignity, which may even predispose him or her
to suicide. It is essential to provide favourable conditions to children that
allow them to live and interact as freely as possible. Likewise, in the
absence of a family member, the child should be provided with a suitable
representative as per section 11 of the Nigerian Child’s Right Act No. 26.
(Nigerian Child’s Right Act No. 26. 2003).
“Every child is entitled to respect for the ‘dignity of his person, and
accordingly no child should be (a) subjected to physical mental or emotional
injury, abuse, neglect or maltreatment, including sexual abuse (b) subjected
to torture, inhuman or degrading treatment or punishment; (e) subjected to
attacks upon his honour or reputation; Or (d) held in slavery or servitude,
while in the care of a parent, legal guardian or school authority or any other
person or authority having the care of the child.” Section 11 of the NCRA No.
26. 2003.
3.2. The rights of the child in research
Authority to consent to participation in health research is the re­
sponsibility of the parents or legal guardian of the child, according to the
National Health Research Ethics Committee (NHREC) 2007. A parent
ought to have precise information before approving a documental con­
sent by writing or voice recording (Policy Statement Regarding Enroll­
ment of Children in Research in Nigeria, 2016).
Section B article 1, Version 1.0 of the Policy Statement Regarding
Enrollment of Children in Research in Nigeria 2016, (PS2.1016). “Enroll­
ment of children below the age of 12 years requires the consent of both
parents or the parent that has primary responsibility for the child at the time
of research or the legal guardian” (NHREC) 2007.
In the case of older children (between the ages of twelve and eigh­
teen), the Act provides them with authority to assent to research. Parents
or legal guardians also need to consent to validate the decision made by
the older child. Notwithstanding the age of the child, the authority to
consent remains with the parents or legal guardian, according to the
National Health Research Ethics Committee of Nigeria (NHREC) 2007.
“For children between 12 and less than 18 years, the child must give
assent while the relevant parent as described in B.1 above, and appropriate to
each specific research scenario gives consent”. Section B articles 2 and 3,
Version 1.0 of the Policy Statement Regarding Enrollment of Children in
Research in Nigeria 2016 (PS2.1016).
A particular group of children who are between the ages of thirteen
and eighteen called emancipated minors (have petitioned the courts to
assume adult responsibilities) can give consent (NHREC) 2007. Conse­
quently, according to the Nigerian Child’s Right Act No 26, 2003, they
can consent in research according to their level of knowledge and
understanding.
“Emancipated minors (in case of children younger than 18 years) can
give consent in their cognizance”. Section B article 4, Version 1.0 of the
Policy Statement Regarding Enrollment of Children in Research in Nigeria
2016, (PS2.1016).
As regulated by the prescriptive norm in the Nigerian Child’s Right
Act No. 26, this provides a practical approach based on the principle of
bioethics ‘nonmaleficence and beneficence’ that the child is not to be
harmed in the research setting. The researcher should respect the dignity
of the subject-child and ensure safety throughout the research. The
researcher should ensure that the child suffers no harm even after the
study. It states that it is wrong for the researcher to abuse the child
during research or even after the investigation. Also, there should al­
ways be measures in place to protect the child from current harm or
future damage to the child’s integrity and dignity. The child should be
treated with respect and should have the liberty to decide what is best
for them and in their interest without coercion.
S.J. Liberty and F.A. Carnevale
“No Nigerian child shall be subjected to physical, mental or emotional
injury, abuse or neglect, maltreatment, torture, inhuman or degrading pun­
ishment, attacks on his/her honour or reputation.” Section 11 of the Nigerian
Child’s Right Act 2003.
4. Discussion
Children’s rights, as supported in the normative documents exam­
ined in this study, recognized children’s right to liberty, protection, and
dignity when consenting to informed care or research and confidenti­
ality. We analyzed the voice of children normatively according to the
prescriptive text - the Nigerian Child’s Right Act No. 26, (NCRA) 2003 -
the supra-legal regulations and descriptive texts; The Medical and
Dental Code of Conduct (MDCC) 2004, the Nursing and Midwifery Code
of Practice (NMCP) 2004 and the National Code of Health Research
Ethics (NCHRE) 2007 -the infra-legal standards. According to the pre­
scriptive text, legal conduct in health care and research with children
should respect the “best interest of the child” (Section 1 of the Nigerian
Child’s Right Act No. 26 2003). However, it encouraged comprehensive
health care and research with children where children voluntarily
participate according to their decision-making capacity under adult
guidance (Article 39 MDCN, 2004; Section 11 of the NCRA No. 26.,
2003; NHREC, 2007). The descriptive text-infra-legal norm; encouraged
the responsibilities of health professionals and researchers to conduct
their duties with less regard to the child’s liberty or autonomy, if the
care is in the “best interest” of the child and society.
Noteworthy, the NCRA 2003 is the national legal document that
protects rights, privileges, dignity, and liberty of the child and the MDCC
2004 and NMCP 2004 are the documents guiding the conduct of medical
doctors and nurses/midwives in Nigeria regardless of the age, sex, race,
culture or religion of the patient. Similarly, the NCHRE 2007 regulates
the activities of Nigerian health researchers. Although Version 1.0 of the
Policy Statement regarding enrollment of children in research in
Nigeria, PS2.1016 (2016) is standing legislation to protect children in
health research, this document is dependant on the NCHRE 2007.
In the present article, we explored the Nigerian Child’s privileges
through the standpoint of normative and regulatory child protection
documents. We assessed children’s rights in healthcare and research
from the view of determining the representation of children’s liberty,
protection, consent, confidentiality, and dignity in practice. Informing
this search are works of literature that postulates the benefits of
involving children in healthcare and research. (Agu et al., 2014;
Bubadué et al., 2017; Carnevale, 2008; Carnevale, Campbell, Collin-
Vézina, & Macdonald, 2015; Committee On BIoethics, 2016; Coyne
et al., 2014; Folayan et al., 2015; Montreuil & Carnevale, 2016). Ac­
cording to the pieces of international literature, the participation of
children in their healthcare and research has disclosed that children are
moral agents with the capacity to provide critical suggestions when
given the opportunity. Recommended ways in which children could be
involved according to the studies included but are not limited to, seeking
children’s consent and protecting their information (Adejumo & Ade­
jumo, 2009; Agu et al., 2014; Bubadué et al., 2017; Carnevale & Man­
javidze, 2016; Cashmore & neglect, 2002; Committee on Bioethics,
2016; Fadare & Porteri, 2010; Kelly & Mackay-Lyons, 2010; Montreuil &
Carnevale, 2016; Coyne & Gallagher, 2011; Grace et al., 2019).
Informed consent involves a contractual ethical, and legal commit­
ment that is established and shared among all participants without
ambiguity in a therapeutic or research setting regarding a procedure or
study. Consequentially, this established agreement between the health
professional or the researcher and the client in the form of signing the
consent document containing the agreed information (Agu et al., 2014;
Committee on Bioethics, 2016; Fadare & Porteri, 2010; Katz, Webb, &
Committee On Bioethics, 2016). Informed consent in pediatrics should
integrate two essential obligations: relating explicit information to the
child and his parents or legal guardian and obtaining legal authorization
on given information before any healthcare intervention or research
5
International Journal of Africa Nursing Sciences 14 (2021) 100284
(Agu et al., 2014; Annas, 2009; Goldie, Schwartz, McConnachie, &
Morrison, 2002; Katz et al., 2016). The prescriptive norm identified the
principle of dignity and justice to necessitate respect for “the best in­
terests of the child” (Section 1 of the Nigerian Child’s Rights Act No. 26,
2003), which may be related to the right to protection for the child.
Nevertheless, this is not the prevalent practice in Nigeria, where parents
or legal guardians or the most senior officer in a health care team makes
decisions (Adejumo & Adejumo, 2009; Adi et al., 2015; Agu et al., 2014;
Ajayi & Dibosa-Osadolor, 2013; Ogunrin, Daniel, & Ansa, 2016; Akin­
wumi, 2010).
Although informed consent has been the standard practice in the
health care system but from this article, we found out that there is a need
to expound on its meaning and practice within the context of children’s
health in Nigeria. This action should give a clear guide to healthcare
providers and researchers regarding the promotion and protection of
children’s rights in Nigeria and Africa at large. Similarly, it is vital to
keep in confidence any consent obtained to ensure trust between health
professionals and clients for quality health delivery, but to what extent
has been a dilemma in healthcare and research with children in Nigeria.
Confidentiality implies that children and adolescents can exercise
their rights by expressing personal views according to their capacity and
remain optimistic about the safety of their commitment without fear of
prejudice from the health professional or researcher (Carnevale, 2012;
Montreuil & Carnevale, 2016; Carnevale et al., 2015). As such, a medical
professional or researcher should not disclose information in therapeutic
or research situations. The Nigerian Child’s Right Act has recognized the
child’s right to freedom of thought, as stated in the Nigerian Child’s
Right Act Section 7, Article 1, “Every child has the right to freedom of
thought, conscience, and religion” (Nigerian Child’s Rights Act No. 26,
2003). Nevertheless, the same law also states in Section 19 Article 2a
that “a child is subject to respect his or her parents, superiors and elders at all
times…”. This law makes it difficult for health professionals and re­
searchers to keep private therapeutic or research information provided
by the child.
Confidentiality may also be affected when the healthcare profes­
sional or the researcher doubts the information provided by the child
according to observable evidence in the situation. Studies showed that
children and adolescents, if given the privilege, can understand, discern
and judge but are constrained by several factors that militate their active
participation (Agu et al., 2014; Cashmore & neglect, 2002; Kelly et al.,
2010; Adejumo & Adejumo, 2009; Bubadué et al., 2017). According to
studies, factors that affect children’s participation include fear of
causing ‘trouble’ by disclosing the origin of a problem, difficulty un­
derstanding medical terms, and fear of asking questions to elucidate the
meaning of what is needed. Others include lack of confidence in the
safety of the given information because they are not familiar with the
health professional or the researcher; lack of adequate amount of time
with health professionals; having a fear of being disbelieved; inattentive
health professionals or researchers; and fear of parents’ reactions
(Adejumo & Adejumo, 2009; Agu et al., 2014; Kelly et al., 2010; Melo,
Ferreira, Lima, & Mello, 2014; Ogunrin et al., 2016).
The privileges of the child as buttressed in the normative texts
respect the right of the child to dignity and liberty, as realized in the
right of the child to guided judgment and voluntary participation in
healthcare interventions or research (Adejumo & Adejumo, 2009; Adi
et al., 2015; Ajayi & Dibosa-Osadolor, 2013; Carnevale & Manjavidze,
2016; Renne, 2010). Therefore, children are supposed to have the
privilege to make choices and healthcare professionals or researchers
should not influence the child’s decision or participation. Children
should be able to get involved in research or healthcare interventions
voluntarily by understanding according to their developmental capac­
ity. Besides, children’s right to be protected should be from the collec­
tive responsibility of the family, society, and the child. Consequently,
since the Nigerian law acknowledges the rights of the child, it should
similarly inculcate that in practice. This practice, we presume, should be
enforced by law overtly in all healthcare practices and research with
S.J. Liberty and F.A. Carnevale
Nigerian children.
The explicit inclusion of children’s voices in Regional, Provincial,
and Federal laws is principal in actualizing the children’s rights.
Countries like Canada and Australia have achieved the inclusion of the
child by representative inclusion of children’s voices in child promotion
and protection programs, thereby giving children a platform to exercise
their rights. Likewise, they encourage children to relate information
with regards to their health from their perspectives (Carnevale & Man­
javidze, 2016; Cashmore & neglect, 2002; Committee on Bioethics,
2016; Katz et al., 2016; Montreuil & Carnevale, 2016; Grace et al.,
2019). These practices have improved healthcare and health research
activities with children in the countries, as mentioned earlier, that are
worth emulating.
This article revealed that, notwithstanding the existence of legal
documents regarding the rights of the Nigerian Child, the code of
conduct for healthcare professionals and research in Nigeria does not
encourage the participation of children in discussion or decision-making
within healthcare or research settings. Also, there are very few studies
on the inclusion of the Nigerian Child in healthcare and research
(Adejumo & Adejumo, 2009; Agu et al., 2014; Ogunrin et al., 2016). A
study conducted to assess the knowledge of Nigerian biomedical re­
searchers comprising of doctors and nurses on the “code of health
research ethics” revealed that there were inadequate knowledge and
limited application of the code of ethics in practice (Ogunrin et al., 2016;
Ogunrin, Ogundiran, Adebamowo, & m. e, 2013). Similarly, other
studies posit that politics, culture, and religious beliefs contend against
the rights of the Nigerian Child (Ogunniyi, 2018; Akinwumi, 2010).
Nevertheless, the recognition of children’s voices requires knowledge of
the child’s capacities and benefits of including children in their care as a
crucial phenomenon to respect the rights of the child. Consequently,
there should be an interaction between the legislature and relevant so­
cietal institutions in structuring laws that possess ethical regard and
promotes moral and legal standards appropriate for healthcare and
research practices. Accordingly, emphasis on statutes that recognize the
voice of children in daily healthcare practices is essential.
5. Conclusion
This article described the rights of the child in the legal premise and
the expected duties of healthcare professionals and researchers within
the existing laws. Studies show that norms regulating healthcare de­
livery have been in existence in Nigeria, but there has not been a clear
guide to laws that are specific to the child in practice. Also, legal prin­
ciples to ethical practice in healthcare have been generalized with only
passive statements regarding judicial conduct in case of dealing with the
child.
In the present article, we normatively analyzed the norms centred on
the respect of the child’s rights as upheld by the principle of dignity and
justice. The principle of dignity is realized to suggest that the right of the
child to information, consent, liberty, and confidentiality must be pro­
tected. According to the normative treatise, regulatory text expressed
respect to the right of the child to involve the freedom of the child to
participate in research or healthcare intervention as a result of
information-knowledge and willingness-consent.
6. Recommendation
Recognition of a child’s voice is essential in healthcare promotion,
and this right should help respect and protect children’s dignity.
Hence, we recommend that the code of ethical practices in the fields
of healthcare and research in Nigeria and Africa at large should be
reviewed to recognize children’s participation rights in healthcare or
research. The active involvement of children in discussions and decision-
making to promote voluntary cooperation in healthcare or research
presents a constructive pathway to health promotion with children.
We also suggest that an unambiguous legal protection document that
6
International Journal of Africa Nursing Sciences 14 (2021) 100284
is specific to the child should be developed to address ethical conduct in
pediatric healthcare practice and create improved awareness among
relevant parties.
Lastly, we recommend that research be conducted to explore and
develop strategies for recognizing children’s voices in Nigerian health­
care practice. We are optimistic that such work can be conducted to help
redress the barriers to the protection, promotion and improvement of
the wellbeing of Nigerian children – informed by their own particular
experiences and voices.
7. Limitations
A limitation of this study is that data collection involved only
nursing, medical, and health research codes of ethical conduct,
excluding other healthcare and research fields. Also, there are insuffi­
cient individualized healthcare field-level documents related to the legal
protection of children in the Nigerian healthcare system to help further
support this study.
8. Authors Statement
The authors confirm that this work has not been previously pub­
lished and neither is it under consideration for publication elsewhere.
Funding
The authors funded the study with support from VOICE (Views On
Interdisciplinary Childhood Ethics) research team.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgment
We are grateful to our research team, VOICE (Views On Interdisci­
plinary Childhood Ethics), for their valuable information that was useful
in the preparation of this article.
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