State Rights, Parental Decisions, and Vaccine Exemptions
How far should state power extend into medical decisions that parents make on behalf of their children? What is a parent’s responsibility to children in the community who have particular susceptibility to harm from infectious diseases? These questions framed the discussion we had last week here at The College of Physicians of Philadelphia on pending legislation in Pennsylvania to eliminate personal belief exemptions to school vaccination requirements. The Honorable James G. Colins, President Judge Emeritus, Commonwealth Court of Pennsylvania, introduced and moderated the event.
Both the bill’s sponsor, Pennsylvania State Senator Daylin Leach (17th District) and Paul A. Offit, MD, argued that personal belief exemptions allow parents to shirk responsibility for keeping their communities safe and healthy. Dr. Offit argued in favor of eliminating even the religious exemption, stating that children should have, under the 14th Amendment, the right to equal protection (from infectious diseases) and that religious exemptions make no sense, given that most religions arose long before the development of any vaccines. (Indeed, many have argued, including Grabenstein, that other than Christian Science, no religions espouse specific doctrinal opposition to vaccination.)
Senator Leach said that he finds it necessary in politics to take incremental steps. While he might support the idea of eliminating the religious exemption, it is much more practical for him to address philosophical exemptions. He argued that individual rights are not absolute – there are limits even to freedom of speech. In the case of protecting children, their rights to remain disease free should not be subject to their parents’ personal beliefs that run counter to accepted medical advice.
Pennsylvania has a relatively low rate of measles, mumps, and rubella vaccination coverage: in 2013-2014, 85.3% of Pennsylvania kindergarteners had received both doses of MMR vaccines, as compared with the nation's median of 94.7%. Leach cited the more than 3,000 current philosophical exemptions to vaccination in Pennsylvania as his target – eliminating those, he said, would go far toward increasing Pennsylvania’s rather dismal rates of vaccination compliance.
Jason L. Schwartz, PhD, the Harold T. Shapiro Fellow in Bioethics at Princeton University, invited the crowd to try to think like a bioethicist when looking at the question of exemptions. He used the metaphor of a safety net when looking at the goal of public health to protect as many individuals as possible from infectious diseases by working toward high immunization rates. And he asked what the best method is for achieving that safety net – he said that nudging parents toward vaccination, perhaps by making personal belief exemptions more difficult to obtain, could be nearly as effective at increasing rates as eliminating the personal belief exemption altogether. Moreover, he said, allowing the very small percentage of emphatic resistors to continue to be able to obtain exemptions would provide a useful safety valve. The right to make medical decisions for one’s family would remain, but using that right to refuse required vaccines would be exercised only by those most opposed to vaccination.
The question and answer period followed with comments about the history of vaccine hesitancy and the benefit of re-framing the night's discussion of state’s rights as societal responsibilities. A few in the audience expressed their strong beliefs that vaccines are unsafe and that they should not have to forfeit their right to public school education for their children given their opinions about vaccines.
Several vaccine resistors emailed me before the event expressing disappointment that their views were not being represented on the panel. Given that this was a policy discussion and not an event about the safety of vaccines, that The College of Physicians of Philadelphia is an organization of physicians, and that the vaccine resistors' beliefs are not supported by evidence, I did not intend to provide an official place at the table for these views – especially when Schwartz ably and rationally presented the argument for what their policy goal is: to maintain the personal belief exemption.
We’ll be following the developments in the Pennsylvania legislature as the exemption bill moves through committees.