Tuesday, January 10, 2012

The Obligation to Vaccinate: "Health Freedom" and communal responsibility

Cross-posted to State of Formation

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


  1. Big fan. I've gotten into heated arguments with some of my colleagues over this point especially in regards to history of medical testing on poor communities of color in this country. While I respect the skepticism that comes with a history of mutual distrust between poor communities and the government, it doesn't negate the real issue of herd immunity that many people ( myself included) rely on in order to stay well. I find it particularly frighting that this issue has come to natural food movement and the upper middle class contingency that can afford to hire lawyers and send their kids to private schools. And, perhaps don't give up on that natural grocery story quite yet. I'd like to think that rational people can be persuaded by logic, and ignorance is a phase. Also I love their teas...

  2. Emily, you do bring up an important point regarding medical testing on poor communities of color. One thing I've found problematic in some (NOT ALL) advocacy for science-based medicine is a tendency not to deal with some of these issues around power and oppression; it's something I think I and other humanities types can bring to the table when discussing the issue, and it's a big part of the reason I chose to write about this on a religious website. I'm not prepared to cede Science Based Medicine as an issue that only atheists get to write about. Those of us of who are people of faith but who also like good science have important things to say on the ethics of SBM.
    As for "that natural grocery store" (I take it you know the one of which I speak ;)), I've been thinking of writing a letter to the NewsTrib on this-- as a matter of fact, what turned into this essay was originally just such a letter. And I think that many folks in [small college town] are frustratingly vulnerable to this sort of crap, so perhaps it's part of my communal obligation to do exactly that.