The Trouble with Vaccine Exemptions

Many people are familiar with the story of Andrew Wakefield. Wakefield was a medical doctor in the United Kingdom. A little over a decade ago, he produced a study purporting to link autism with the MMR (mumps, measles, and rubella) vaccine. The most distinguished medical journal in the UK, The Lancet, published the study. Not long after, widespread fear grew over the potential link between the vaccine and autism—except that there was no such link. Wakefield deliberately fabricated the data for the study and subsequent studies (of which there were many) proved that the MMR vaccine does not cause autism. The supposed causative agent in the vaccine, a mercury-based preservative known as thimerosal, was removed as a precaution. Eventually, Wakefield’s fraud was uncovered and The Lancet officially retracted the study. The UK’s medical licensing authorities took away Wakefield’s medical license shortly thereafter. Wakefield left the UK and now lives in Austin, TX, where he continues to advocate the disproven link between vaccines and autism.

The reaction against vaccines spurred the adoption of more and looser public school vaccine exemption statutes in many states. Wakefield’s fraud was in no small part a driving factor in this development. Even though Wakefield is now unmasked, many of these exemptions remain. Most of those against vaccines either rejected the scientific consensus, or found other largely pseudoscientific reasons to avoid giving their children vaccines. Vaccine exemptions are an important legal tool. They allow a student with genuine medical or religious exemptions to avoid compromising their health or violating their beliefs. Many states, however, rarely do more than require a parent to affirm that they fulfill the criteria for an exemption. Worse, more than a dozen states now allow so-called philosophical exemptions. Basically, if a parent simply has a bona fide belief that their children should not be vaccinated, then they can opt out.

Vaccine exemptions, however, do not affect only the child who does not receive the vaccine. An important part of vaccines’ effectiveness is the herd immunity resulting from mass vaccination. Even if one child does not develop immunity or still gets a disease, the disease cannot spread to the immune children around the sick child. In essence, herd immunity chokes off the spread of a disease until it is extinct. Nevertheless, the widespread availability of exemptions is causing cracks in this herd immunity. Thus, the “philosophical” decision not to vaccinate one’s child potentially imperils other children as well. Many of these childhood diseases are not well understood by parents because they were brought under control or wiped out in the United States long ago. Many can be life threatening . The legal framework of vaccine exemptions, which is not based in sound scientific evidence, is creating a dangerous and growing public health problem. It is up to policymakers to chart a wiser course not based on bad data and false fears of parents. Otherwise, many diseases we had long thought vanquished may make a comeback among the youngest members of our society.

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6 thoughts on “The Trouble with Vaccine Exemptions

  1. I tend to disagree with this analysis of vaccine exemptions. I understand public policy requiring that citizens follow certain rules (such as paying taxes), but shouldn’t a person have the exclusive right to control what they put in their body? Public health is certainly a concern, but there is a big difference between preventing epidemics by maintaining sanitation or educating the public and requiring individuals to put a substance in their body. Requiring vaccinations across the board would create a slippery slope. At what point would we draw the line on what medical treatment is required as a matter of public policy and what we have the right to refuse? Would we have widespread legislation on what foods we are allowed to eat? Would we be required to take antibiotics for certain conditions. Plus, requiring vaccinations in those who are opposed for religious reasons would violate the Constitutional right of freedom of religion. Requiring some sort of documentation or “valid” reason for refusing vaccines is equally problematic because who gets to determine what is “valid?” Dictionary.com defines religion as “a set of beliefs concerning the cause, nature, and purpose of the universe… and often containing a moral code governing the conduct of human affairs.” If one’s beliefs or moral code includes seeking out natural remedies rather than turning to Western medicine wouldn’t this be protected by freedom of religion?

    While I understand the epidemiology side of the argument, from the legal and individual rights perspective I do not think that legislators can, in good conscience, require all people to be vaccinated. Our government has many important functions in keeping our society running, but the government should not be able to legislate personal choices about health. It is certainly true that the side effects of most vaccines are mild in comparison to the disease that they are preventing, but if someone would rather risk contracting the disease then they should be allowed to do so. Promoting more education on vaccine safety would be a less controversial solution and would encourage most parents to get their children vaccinated.

  2. The Supreme Court held in Jacobson v. Massachusetts, 197 U.S. 11 (1905), that a person can be compelled to submit to vaccination or face a criminal penalty. The court held that “[e]ven liberty itself, the greatest of all rights, is not unrestricted license to act according to one’s own will. It is only freedom from restraint under conditions essential to the equal enjoyment of the same right by others. It is, then, liberty regulated by law.” Interestingly, the reason that Jacobson didn’t want his smallpox vaccination is that he didn’t believe that it would work, which was objectively incorrect. The Court rejected this argument, which Jacobson based on the due process right found in the Fourteenth Amendment, holding that it was not arbitrary and unreasonable to give a health board the power to compel vaccination in the face of a devastating disease.

    The main point from Jacobson is that all rights, including religious liberty, are subject to regulation when they begin to endanger others. Obviously we wouldn’t allow human sacrifice for religious reasons—nobody believes that religious freedom is absolute. But compelling you to eat your broccoli and requiring you to get a vaccination are inherently different: if I don’t eat my broccoli, the greater weight of the harm falls on me, but if I don’t vaccinate myself or my child, then a danger almost as great as the one to myself attaches to every single person who comes in contact with me. In practice, people do die because others choose not to be vaccinated. Following this basic reasoning, no vaccine exemption is required as a matter of constitutional law. Whether they exist or not is a question for state legislators.

    Nevertheless, my post does not advocate compelled vaccination. I would retain religious and medical exemptions, although I would strengthen the review process for both (especially for religious exemptions) to ensure that the religious belief is bona fide. Any parent who wished to invoke an exemption should have to consult a pediatrician on the risks of forgoing vaccination. A similar provision is already in place in two states, and a bill is in front of the governor of California right now. (California has one of the highest rates of exemption, and the rising cases of whooping cough there, a potentially fatal disease, are attributed to this fact). Further, I would compel those children to be assigned randomly to other schools to keep too many unvaccinated children from being in the same place. I am most concerned, however, with philosophical exemptions, which basically amounts to allowing any person to refuse to have a child vaccinated for any reason. I do not see any need for such an exemption, since they allow uninformed people to refuse vaccination for their children on specious grounds.

    • I completely agree that those who choose not to vaccinate their children should have to consult with a pediatrician or some other professional who can educate them. Uneducated decisions and misinformation are both dangerous. However, for educated parents who believe that medicine should only be used when absolutely necessary, it seems that they should be able to refuse vaccinations without too much hassle. Vaccinations that prevent highly contagious diseases such as measles, whooping cough, polio, and diptheria should certainly be emphasized and encouraged. From a public health standpoint, these vaccinations are more important than vaccinations that prevent diseases that could also be prevented by smart lifestyle choices (such as Hepatitis), are not easily passed to healthy people from infected people (such as tetanus), or only cause disease in a small percentage of infected people (such as HPV). Don’t get me wrong, I certainly think vaccinations are an important part of both preventative medicine and public health and I am certainly not saying your opinion is wrong, I just have concerns about where we would draw the line.

  3. To me, at least, this is exactly the reason why philosophical exemptions are bad. To say that medicine should only be used when absolutely necessary is irrational. It is especially irrational in the case of vaccines. My basic point is that you can be as irrational as you want when it doesn’t endanger me or anyone else—but in the case of vaccines, the irrational choice is endangering other people with little tangible benefit to the person invoking the exemption or to society as a whole. If you balance the two, it seems to me that the choice comes down to requiring the vaccination of the child, regardless of the personal belief of the parent because the risk to society is so much greater than the benefit of indulging an irrational belief.

    I also don’t agree with the dichotomy between “highly contagious disease” and those “prevented with smart lifestyle choices.” Hepatitis B is a highly contagious disease, and it’s not only spread by sexual contact; in fact, a large percentage of cases occur in childhood. Hence, this is why it is a required vaccination for elementary school students. HPV is also highly contagious, although the three sexually transmitted strains of HPV in Gardasil are admittedly unlikely to spread in elementary school students. However, there is the countervailing consideration that the best way to prevent HPV infection is to encourage vaccination before the onset of sexual activity. Hence, this is why the vaccination might be required for elementary students. Therefore, I don’t think it is possible to draw the distinction that you make.

  4. I prefer to be vaccinated and vaccinate my children. However, not getting vaccinated is not irrational, as vaccination is not risk-free: http://www.cdc.gov/vaccines/parents/vaccine-decision/side-effects.html

    Here is a great article explaining why the behavior involved in not getting a vaccine is not irrational:
    http://scienceblogs.com/mikethemadbiologist/2009/05/28/behavioral-economics-not-every/

    So, please do not throw around the word “irrational” with such flippancy.

  5. I would never argue that vaccination is “risk free” in the sense that it’s literally impossible to have a reaction. Egg is a common vaccine ingredient, but some people have allergies to it. This is the purpose of medical exemptions, because they protect people with bona fide medical reasons like egg allergies from having to comply. This CDC page (http://www.cdc.gov/vaccines/vac-gen/side-effects.htm) actually quantifies the risk of serious complications for each type of available vaccine and demonstrates that it is extremely small. The CDC page you link to has information about the dangers of not being vaccinated and states “The most common side effects are mild. On the other hand, many vaccine-preventable disease symptoms can be serious, or even deadly,” so I’m not sure it really in any way supports the argument you are trying to make.

    Furthermore, choosing not to get vaccines is actually, ceteris paribus, irrational from a risk perspective. You are presented with these facts: (1) vaccines are exceedingly effective at preventing life-threatening diseases, especially in childhood; (2) the risk of a severe reaction to vaccines is generally less than 1 in 1 million (or even smaller) as shown in the CDC page you cite to, and not all vaccines even have recorded cases of severe reactions; (3) failure to get a vaccine not only endangers you but the people around you; (4) injuries related to vaccines are compensated by a federal government program and the CDC provides this information at the time of vaccination. It is the very definition of irrational to choose to forgo vaccinations for your children in light of these facts. I’m not sure what the behavioral economics page you cite to has to do with this. Economics, as a social science or “soft” science is a different field altogether from medicine, an evidence-based, “hard” science.

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