Health versus Freedom of Conscience

For many years it has been the law in most places that children are required to be immunized for the common childhood infectious diseases before entering school. State laws establish these rules, so there is variation from state to state regarding what vaccines are required, whether there are subsequent requirements for booster shots in upper grades, and whether there are opt-out provisions for individual families. The logic behind mandates for immunization is that community welfare takes precedence over the individual right to choose. Actually, the laws don’t force vaccination. Parents have the option to bypass the public schools, through private schools or home schooling.

One of the common exemptions for vaccination requirements is religious objection. There are people who believe their religion prohibits immunization. Some fundamentalists might believe that since the Christian Bible is silent about vaccination, it should not be done. Some others believe God will take care of the faithful, and that medical procedures demonstrate lack of faith. Christian Scientists believe illness is due to emotional upset and anxiety; a positive state of mind is the main ingredient of good health. Perhaps most families seeking religious exemption are sincere in wanting to practice their own religious convictions. An unknown number of religious exemptions are smoke screens for distrust of government or misguided notions about the hazards of vaccines.

This week I learned that two U.S. states make no provisions for religion-based vaccination exemptions: Mississippi and West Virginia. Most state exemption provisions require families to articulate, in writing, the religious basis for their vaccination dissent. It is not enough to just say they are opposed on religious grounds. A smaller number of states have a vague category called “philosophical or conscience objection” which gives people a more vague opt out. Rates of religious exemption vary from state to state, but they are increasing; CDC estimates around 40,000 children per year get religious exemptions for school entrance-required immunizations. This is a small number compared to the overall school population of over 50 million. Nevertheless, the unimmunized children present a threat to themselves and to others.

This presents a dilemma for health promotion. The nation’s founding fathers were concerned enough about religion that it is mentioned first in the Constitution’s Bill of Rights, in the so called establishment clause: “Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof…” On the other hand, the Preamble to the Constitution stipulates one of the purposes of the powers established by it is to “promote the general welfare.” Surely protecting our communities from infectious disease epidemics is in the category of general welfare.

Since there is no specific mention of public health in general, or immunization in particular, we are bound to follow the 10th Amendment, which by default leaves the matter to the individual states. If the time comes that religious-grounded vaccination exemption needs to be reconsidered because of rising infection rates, there will be messy political battles in each state.

Our system encourages messy public policy battles; this is one of the things that makes our system great. Many good things are messy, including healthy children, but what a blessing they are!