The Obligation to Vaccinate: “Health Freedom” and communal responsibility

While visiting my hometown over winter break, I stopped by the local natural foods store. As I waited at the cash register, I noticed a poster on the wall.  Above a stock photo of a (white) mother blissfully cradling a newborn read the caption, “Oppose Mandatory Vaccination.”

Two thoughts came to mind. First, “I will no longer spend money here.” Second, “What beliefs and fears is this poster trying to exploit?” With the language of “mandatory,” the ad clearly speaks to a fear of losing the individual freedom to make choices about health. But is freedom really the best framework to use in this scenario? Or was the ad a demonstration of how individual freedom is a poor premise on which to base discussions of public health?

The anti-vaccine movement, in its contemporary iteration, began in 1998 when the British doctor Andrew Wakefield published a paper in the medical journal The Lancet, positing a link between the Measles, Mumps, and Rubella (MMR) vaccine and autism. Subsequent studies failed to corroborate Wakefield’s claims; indeed, evidence strongly suggesting that Wakefield’s work was not only incorrect, but actively fraudulent, has since come to light. None of this has stopped the vaccine-autism claim (which grew from a specific focus on the MMR vaccine to equally inaccurate claims about mercury-based preservatives and about “too many vaccines too soon” overwhelming the immune system) from sweeping the public consciousness in a big way, aided most notably by figures such as David Kirby, Robert F. Kennedy, Jr., and Jenny McCarthy.

Tragically, the spread of this claim has had consequences: Measles, which in the mid 1990s was on the verge of eradication in the United Kingdom, has returned to endemic levels. This past year saw the largest U.S outbreak of measles in 15 years. And in Charlottesville, VA, where I live, there was a measles outbreak centered around the local Waldorf school this May.

In addition to the fact that the claims on which the entire movement is based are incorrect, and that the drop in vaccination rates precipitated by the movement is likely responsible for actually killing people, there are several other troubling premises behind it: can we, for instance, pause to note the breathtaking ableism of the assertion that risking a child’s death from infectious disease is preferable to risking autism?

Equally troubling is the callous disregard of scientific consensus in favor of conspiracy theory, as well as the “Appeal to Nature” fallacy. (I would suggest that those who oppose vaccination because it does not confer “natural” immunity cease, in the name of intellectual consistency, any use of corrective lenses, contraceptives, refrigerators, computers, and so forth.)

I am most interested in here, however, in vaccine refusal as a “right.” I think this language has a particularly strong pull within religious communities. Certainly the idea of being forced to take actions contrary to one’s strongly held beliefs is anathema to many people of faith, particularly those who belong to minority traditions.

And the language of “health freedom” often used in arguments for vaccine refusal echoes that of “religious freedom”—after all, if what we do with our souls is a matter of the most personal choice, surely this is also true for our bodies? Don’t we have the right to make whatever healthcare decisions we wish, however ill-advised, for ourselves and our families?

Not quite.  Not all bodily decisions are created equal. As the rise in measles rates indicate, the decision not to vaccinate has consequences for more people than those who make that decision. Indeed, as Steven L. Weinreib, M.D, pointed out in a recent New York Times op-ed, high vaccination rates are an essential bulwark against infectious disease for those who, because they are too young, have certain allergies, or are immuno-compromised, cannot be vaccinated:

Young babies, the immuno-compromised and people who get chemotherapy are not able to process most vaccinations. Live vaccines in particular, like those for measles and chickenpox, can make us sick. But if 75 percent to 95 percent of the population around us is vaccinated for a particular disease, the rest are protected through what is called herd immunity. In other words, your measles vaccine protects me against the measles.

Weinreib’s point demonstrates that the language of individual rights is insufficient when considering the ethics of vaccination and similar public health issues. Instead of thinking, “It’s my right to refuse a vaccination for myself or my child if I want to,” we should be thinking, “It’s my responsibility to vaccinate myself and my child for the health of the whole community.”

In Health Care and the Ethics of Encounter: A Jewish Discussion of Social Justice, Laurie Zoloth argues precisely this point:

At issue here is not what feels right to the individual, guided by an individual heart, but ‘What does it take to live an honest life within this particular community?’ Hence, a number of actions may be argued for, but all ought to be directed toward the community interest, not only the self. (Zoloth, 1999, 158)

Furthermore, Zoloth argues, the Jewish tradition provides a framework for such community-centered ethics: “Autonomy…is neither a presupposition nor a goal of Judaism…[a person is not] ‘entitled’ to act in complete freedom; he or she is required to act in community, in covenant with God, and in accordance with halakhah.” (Zoloth, 158)

One source for the primacy of communal obligation is the book of Ruth (in which Naomi’s family flees a famine-stricken Bethlehem for Moab, and is afterwards stricken with the deaths of all its male members), from which she derives several principles of an “ethics of encounter.” The first of these is particularly salient here: “To leave the community at a time of scarcity/danger is wrong. There is no personal escape from collective scarcity:”

Why does disaster fall upon this family? Who is [Naomi’s husband] Elimelech? The rabbinic response is that he must have been a man of substance, who abandoned Bethlehem at the first sign of trouble…Elimelech is the prudent libertarian. [He] chooses his individual solution, leaves the land and the community, and disaster strikes. Rather than turn his face to the face of the other, he turns away and heads in the opposite direction. (Zoloth, 204)

If we replace “scarcity” with “risk” in Zoloth’s formulation, we find it applies perfectly to the issue of vaccines and herd immunity.

It’s true that vaccines are not without risk. A small minority of people do react badly, and there is the occasional fatality (at rates, it should be noted, that are miniscule compared to the toll of infectious disease). To vaccinate is to take a risk, albeit a very small one, for the sake of a greater personal and communal good. With vaccination rates as high as they are in the developed world, any given person can go unvaccinated and will likely remain quite safe; this is also what protects those who cannot be vaccinated or for whom vaccine-conferred immunity does not take.

But too many defections, and the herd immunity that newborns, immune-compromised individuals, individuals for whom the vaccine did not work, and those who voluntarily refuse vaccination depend on will collapse. Those who refuse vaccination based upon a claim of individual autonomy thus behave exactly like Elimelech in this story—fleeing the community at the first sign of risk, and disclaiming their membership therein.

That the eradication of infectious disease depends upon a community upholding its responsibility to protect its citizens cannot be overstated. Precisely because of the nature of infectious disease, it is impossible to protect oneself by withdrawing from the community. Unless you can figure out how to stop breathing air, stop drinking water, stop eating food, and stop engaging in any physical contact with anything else, you will come in contact with vectors for infectious disease as a consequence of existing. This is a risk we share as a community; its amelioration is a responsibility we similarly share as a community. The vaccine issue is an object lesson as to the validity of Zoloth’s argument for the value of an ethic based on communal obligation in issues of health.

Cross posted to my personal blog.

This public domain image is a work of the Federal Government and appears courtesy of Wikimedia.

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6 thoughts on “The Obligation to Vaccinate: “Health Freedom” and communal responsibility

  1. Wonderful piece, Rebecca.

    Given that, as you say, the risk of vaccinating is miniscule in comparison to that of not vaccinating, I wonder if it makes sense to call it a ‘risk’ at all. No choice is absolutely risk free, but given that one must either vaccinate or not, and that the latter option is statistically riskier, I wonder if it already grants too much to the skeptics to call vaccination a risk! The risk (for communities and individuals alike) is not vaccinating.

    I quibble. Thanks for this.

    Mark

  2. Mark,

    I hesitated when I wrote that part, for exactly the reason you cite here. I decided to keep it, for three reasons:
    1. I think that, given the vagarities of human psychology, we have a tendency (however factually incorrect) to perceive acting as riskier than failing to act. Thus, even though (as you correctly point out) statistically speaking it is riskier not to vaccinate than it is to vaccinate, a person might see the act of vaccinating as taking a risk, precisely because it involves acting.
    2. I think that failing to acknowledge the risk, however minimal, can also play into the denialists’ hands by providing them with a convenient strawman. If I say, “vaccines are, relatively speaking, risk free,” I worry that can be easily spun as, “Look! The establishment wants you to believe that there are no risks– but here’s an anecdote about a child who had an allergic reaction and died!” At that point, even though I’m factually correct, the denialists have me over a barrel, rhetorically speaking, because they have an intellectually dishonest–but emotionally compelling– story.
    3. Statistics are probably cold comfort if you or your child are one of that miniscule set that does have a serious reaction. I don’t think it does our cause any favors not to acknowledge that it happens. If we fail to acknowledge that, then the families of those so affected may feel (not unjustifiably) erased, which turns us into the insensitive bad guy. In order to win this fight, I think it’s critical that we present ourselves as compassionate and humanitarian, and that means listening to and acknowledging people’s fears. If I say, “I understand why you feel that way. These statistics may help allay these fears” to the average parent, I think I stand a greater chance of convincing them than if I begin with “You’re wrong.”

    Now, regarding those who are actively spreading anti-vax propaganda, the above clearly does not apply.

  3. Great piece Rebecca.

    The issue of social responsibility for immunization for the greater social good extends to other areas. An example in my field is getting increasing interest: keeping malware (viruses, worms, bots) off your computer. The risk to the individual from having their computer infected may be relatively minimal (the more sophisticated malware keeps itself hidden, and doesn’t use up all your disk space or slow your computer down except when you’re not using it), but the social impact can be severe – spam, distributed attacks on sites, and lots of other things.

    So there are many proposals to require some measure of immunization of computers – whether that’s enforced by your ISP refusing to allow you to connect if you fail some sort of test, or the vendor of your operating system providing a “health certificate” that your computer is up to date on patches, or legal penalties if your computer attacks other computers even if you were unaware it was infected. Yes, some computers may “react badly” to a “vaccination”, and it may even cause some computers to become unusable, but maybe that’s an OK price to pay.

    Granted, malware on your computer is (generally) not likely to cause life-threatening impacts as lack of vaccination can, but the economic and potential national security impacts are pretty bad. So is there an ethical responsibility, as well as a potential legal one to keep your computer clean?

    It’s quite easy to take your piece, make very minor edits, and have it appropriate to computer security!

    I love when our fields intersect!
    –Jeremy

  4. Very interesting article. This topic is indeed a hot one. I will offer a few thoughts from an opposing point of view as food for thought.

    I am the mother of a vaccine injured child, MMR in fact. I spoke with my doctor about the risks involved in vaccinating my other children. He said that there are cures for Measles Mumps and Rubella. There is no cure for autism. Take a good drink of that and let it settle in. Swish it around in your mouth and taste it. No cure. Fortunately, he was wrong. My son was cured through prayer, diet, enzymes and homeopathy. I do know, personally though, parents who are facing a lifetime with children who do not speak, who endlessly stim, who scream at the touch of water or at particular sounds.

    Also, consider the huge amounts of money that go into the vaccine industry and the financial stake they have in discrediting people like Dr. Wakefield. (Who has since been cleared by the way, but not in time to save his name from the slander.) Huge amounts of money are being made offering every manner of vaccine! Get your flu shots at work, your shingles vaccine at the grocery store, never mind that your actual risk of getting shingles might be next too zero! It is a truly irresponsible trend, backed by none other but the dollar!

    There are in fact, other scientific opinions on the issue of vaccination. For instance my homeopath was the nurse in charge of vaccine compliance for the staff at a major hospital for many years… until she developed Lupis as a result of the constant onslaught on her immune system from being vaccinated repeatedly for compliance with hospital regulations. Not many people are aware of the fact that vaccines only offer protection for a few years and must be re-done repeatedly to continue protection. Homeopaths look at the whole picture of health and not just the one targeted disease. As vaccines have increased, so have other major diseases. Heart disease, diabetes, cancer are all rising as vaccination does. Looking at the whole body picture, the body needs to get sick with little things like the flu in order to learn how to fight off big things, like cancer. These days we vaccinate irresponsibly for every little sickness and rob the body of the knowledge of how to heal. As soon as we “authenticate” politically one strain of medical thought against others, we loose the potential for competition and improvements to human health. If you doubt, check out what happened to homeopaths and allopathic physicians with the formation of the AMA. Allopaths (MD’s) were loosing patients as their treatments with mercury and bleeding patients were not working and more patients began to choose homeopaths. Allopaths saw this and formed the AMA. Homeopathy was made illegal for many years and the allopaths took over. The income of allopathic MDs soared and a very useful form of medicine was nearly lost in the process.

    Let’s not make the government our god and give over all our freedoms and choices to the government. We have One God in whom we trust and it’s not government. Government as god has been tried historically many times and failed miserably.

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