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Religious Exemptions to the Immunization Statutes: Balancing Public Health and Religious Freedom

Published online by Cambridge University Press:  01 January 2021

Lainie Friedman Ross  and
Timothy J. Aspinwall
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Extract

In February 1997, the Committee on Bioethics of the American Academy of Pediatrics (AAP) updated its position on religious exemptions to medical care. In its earlier statement, the committee noted that forty-four states have religious exemptions to the child abuse and neglect statutes, and they argued for the repeal of these exemptions. The committee did not indude in its statement a position on religious exemptions to childhood immunization requirements that exist in forty-eight states, although this issue was discussed in committee meetings. In its revised statement, the committee concluded that “The AAP does not support the stringent application of medical neglect laws when children do not receive recommended immunizations.” In this paper, we consider whether failure to immunize one's child is a form of medical neglect and, if so, whether states should repeal their religious exemptions to the immunization statutes. We argue that failure to vaccinate a child properly is medical neglect.

Type
Article
Information
Journal of Law, Medicine & Ethics , Volume 25 , Issue 2-3 , Summer Fall 1997 , pp. 202 - 209
Copyright
Copyright © American Society of Law, Medicine and Ethics 1997

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References

Committee on Bioethics, American Academy of Pediatrics, “Religious Objections to Medical Care,” Pediatrics, 99 (1997): 279–81. This committee statement updates that committee's previous statement in 1987. See Committee on Bioethics, American Academy of Pediatrics, “Religious Exemptions from Child Abuse Statutes,” Pediatrics, 81 (1988): 169–71.Google Scholar
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Vaccination coverage necessary to achieve herd immunity depends on the disease; for example, measles and pertussis, 92 to 95 percent; mumps, 90 to 92 percent; rubella, 85 to 87 percent; and diphtheria and polio, 80 to 85 percent. See Anderson, R. and May, R., “Modern Vaccines,” Lancet, 335 (1990): 641–42.CrossRefGoogle Scholar
In its review of the data, the AAP concluded that no causal relationship exists between DTP (diphtheria, tetanus, and pertussis) vaccination and chronic neurologic disorders. See Committee on Bioethics, American Academy of Pediatrics, “The Relationship Between Pertussis Vaccine and Central Nervous System Sequelae: Continuing Assessment,” Pediatrics, 97 (1996): 279–81. Similar conclusions have been reached by the National Vaccine Advisory Committee. See National Vaccine Advisory Committee, Report of the Ad Hoc Subcommittee on Childhood Vaccines (Washington, D.C.: U.S. Department of Health and Human Services, 1994); and Advisory Committee of Immunization Practices, Centers for Disease Control and Prevention, “Update: Vaccine Side Effects, Adverse Reactions, Contraindications, and Precautions. Recommendations of the Advisory Committee of Immunization Practices,” Morbidity and Mortality Weekly Report, 45, no. 2 (1996): 1–35.Google Scholar
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The burden on religious freedom created by this option is similar to the burden of a religiously objectionable curriculum: Parents who object to the conditions at public schools may choose to send their children elsewhere. This burden is not excessive. But given the alternatives regarding immunizations, we question whether this represents an optimal balance.Google Scholar
For an excellent article on this topic, see Cole, P., “The Moral Bases for Public Health Intervention,” Epidemiology, 6 (1995): 78–83.Google Scholar
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The Comprehensive Childhood Immunization Act of 1993 was devised to overcome financial barriers to immunizations. 42 U.S.C.A. § 1396s (West 1997). The Act mandates that the federal government provide vaccines to physicians at no cost for children who are enrolled in Medicaid, who are Native Americans, and/or whose parents' insurance does not cover immunizations.Google Scholar
The Immunization Information Systems promoted by CDC are methods of tracking and identifying those children who need to be vaccinated.Google Scholar
There are a number of reasons why the Comprehensive Childhood Immunization Act of 1993 has only been partially successful. First, qualifying primary care providers may charge to cover the cost of administering the vaccine. 42 U.S.C.A. § 1396s(a), (c), (d). Although a participating physician may not refuse to vaccinate a child who cannot pay this fee, financially needy parents may not know this or may be reluctant to ask for a fee waiver. Second, physicians are required to determine whether the child qualifies for the vaccination program, and the physician is required to keep records to verify the child's qualifying status. 42 U.S.C.A. § 1396s(c)(2)(A)–(C). The bureaucratic requirements may deter physicians from participating in the program. The result is that many qualifying children may be unable to get these vaccines except in public clinics. For proposals to remove access barriers, see American Academy of Pediatrics, “Implementation of the Immunization Policy (S94-26),” Pediatrics, 96 (1995): 360–61. The Immunization Information Systems also have problems. Opponents have serious ethical concerns related to privacy and confidentiality of the records. See, for example, Gostin, L.O. and Lazzarini, Z., “Childhood Immunization Registries: A National Review of Public Health Information Systems and the Protection of Privacy,” JAMA, 274 (1995): 1793, 1794.Google Scholar
The AAP's Committee on Bioethics also supports “mandatory mass vaccinations in epidemic situations.” See Committee on Bioethics (1997), supra note 1, at 280.Google Scholar
We do not address whether the state has the moral right to act paternalistically toward adults. Some ethicists, however, question the state's right to mandate any public health measures for children or adults. See, for example, Veatch, R.M., “The Ethics of Promoting Herd Immunity,” Family and Community Health, 10, no. 1 (1987): 44–53. In this paper, Robert Veatch questions state-mandated universal immunizations because he thinks no one benefits from the promotion of herd immunity.Google Scholar