Our congregation has a policy that children who have not received the standard immunizations will not be admitted into our religious school. Recently, this policy has been challenged by several member families, who object to some of these immunizations as excessively risky and who have therefore not immunized their children. Attempts to reach a compromise have failed, and these families have now left the congregation. Is our immunization policy correct and justifiable according to Jewish tradition? (Professor Marc Bernstein, Ann Arbor, MI)
1. The Mitzvah of Medicine. Any discussion of our she=elah must begin with this fundamental fact: Jewish tradition regards the practice of medicine as a mitzvah, a religious obligation. It is an aspect of pikuach nefesh, the preservation of human life, a mitzvah that takes precedence over virtually every other requirement of the Torah. Even the rules of Shabbat and Yom Kippur are superseded in order to save life, and medicine falls under this instruction. Should an Aexpert@ or Acompetent physician@ (rofe uman or rofe baki) prescribe a remedy for a patient with a serious illness, the patient must accept the remedy even if its preparation and application would normally violate the prohibitions of those holy days. One who refuses this treatment on the grounds that he or she prefers to observe the laws of Shabbat Ais a pious fool (chasid shoteh). This is not an act of piety but of suicide. He is compelled to do what the physicians prescribe.@Although our tradition speaks of a variety of acts that might be undertaken by and on behalf of the sick, such as teshuvah (repentance), tefilah (prayer), and tzedakah (giving to the poor), we are nonetheless required to follow the law of nature and to call the physician when we fall ill. Whoever refuses medical treatment in favor of the other, non-natural responses, is guilty of the sin of arrogance, of assuming that one deserves to be healed by way of a miracle.
It follows from all this that we are obliged to accept appropriate medical treatment and to provide it to our children, for their health and well-being is our responsibility. The key word here is Aappropriate@: we are not required to accept medical treatment that serves no legitimate therapeutic purpose. If a course of medical treatment is not therapeuticBthat is, if it does not contribute to the successful treatment of diseaseBit does not qualify as Ahealing@ (refu=ah) as Jewish tradition understands that term. It ceases to partake of the mitzvah of pikuach nefesh, and hence it ceases to be obligatory. The precise definition of terms such as Atherapeutic@ and Asuccessful treatment,@ as we have written elsewhere, is difficult to establish with precision. Still, our tradition does distinguish between therapies regarded as Aproven@ (refu=ah vada=it or refu=ah bedukah), which offer a reasonably certain prospect of successful treatment, and those that are experimental or untested, which offer but an uncertain therapeutic benefit. We are required, the authorities tell us, to accept Aproven@remedies; they are pikuach nefesh, and we have no right to refuse them. On the other hand, we are not required to accept medical treatments that are Aunproven,@ of dubious therapeutic value.
This distinction is of critical importance to the case before us. The parents in question claim that the immunizations required by their congregation pose excessive risks to the health and safety of the children who receive them. If this claim is correct, then Jewish tradition may well support the refusal of these parents to immunize their children, for Aexcessively risky@ treatments might not be regarded as legitimate medicine. Indeed, a therapy that poses an unacceptable danger to life can hardly be said to fulfill the mitzvah of pikuach nefesh.
The questions we must answer are these. Do immunizations qualify as refu=ah bedukah, as proven remedies? Do they offer a reasonably certain prospect of successful treatment, in this case, the prevention of dangerous diseases, or are their therapeutic benefits dubious at best? Granted that no medical therapy can be entirely free of risk, do vaccines pose a level of danger that outweighs their benefits? And even if we regard vaccines as a clear and positive good, is it the proper concern of a synagogue (or any public body for that matter) to require that children be immunized?
2. Immunization as Refu=ah. AImmunization@ is the process of artificially inducing immunity or providing protection from disease. There are two forms of immunization: Aactive immunization,@ by which the body is stimulated to produce antibody and other immune responses through the administration of a vaccine or toxoid; and Apassive immunization,@ the provision of temporary immunity through the administration of preformed antibodies derived from humans or animals.
Not so long ago, infectious disease was counted as the most serious threat to human life. Its effect upon children was devastating: of every 1000 children born in 1900, 160 died of an infectious disease before the age of five. Today, by contrast, Aparents in the developing world no longer fear these diseases.@ This welcome change, surely one of the great success stories of the twentieth century, is largely due to vaccines, which Aare among the most effective means of preventing disease, disability, and death.@ The ultimate goal of immunization is the eradication of disease, and the model for this eradication is the experience with smallpox. This once deadly killer was eliminated from the world in 1980 through a combination of a worldwide campaign of immunization, surveillance, and adequate public health control measures. This experience has been repeated time and again. Prior to the development of the Salk vaccine in 1955, paralytic poliomyelitis claimed up to 18,000 victims in the United States during epidemic years; today, this number is down to five to fifteen cases per year, primarily among those who for some reason have not been immunized. Diphtheria was once a common respiratory illness, with a 5% to 10% fatality rate; today, fewer than 100 cases are reported in the United States each year. Before the 1960s, well over 500,000 cases of measles occurred each year in the United States, and one out of every fifteen children who contracted the disease during the large epidemics died from it. Today, the incidence of measles has been reduced by 99%. Worldwide, it is estimated that at current levels of immunization, 3.2 million deaths from measles and 450,000 cases of paralytic polio are prevented each year and that another 1.2 million measles deaths and 12,000 cases of paralytic polio might be prevented if full immunization is achieved. During a rubella epidemic in 1964-1965, 20,000 infants born to mothers infected during pregnancy suffered from blindness, heart disease, and mental retardation. AToday, thanks to nearly universal use of an effective vaccine, the rubella virus poses virtually no threat to the children of expectant mothers.@ In addition, immunization has brought with it an enormous economic benefit, for it is far more efficient to prevent a disease than to treat it. Recent studies in the United States suggest that each of the traditional vaccines is cost saving in terms of direct medical costs alone and that an integrated immunization program saves $7 to $9 for each $1 spent. It is true, of course, that immunization is not the only factor to be credited in the successful battle against these diseases. Other measures, such as improved nutrition and sanitation, play an important role as well. Yet in the absence of effective vaccines these other measures would not have produced the impressive life-saving results that we have witnessed in our time. Thus, in addition to all other disease-fighting tools, Aevery health authority with responsibility for child health must have a well-organized program of immunization as locally appropriate.@ These programs are often made compulsory for the residents of the particular community. In the United States, the schedule of immunization for children is determined by the Advisory Committee on Immunization Practices of the U.S. Public Health Service and the Committee on Infectious Diseases of the American Academy of Pediatrics. All states require immunization of children at the time of entry into licensed child care and entry into school. In addition, many states have regulations requiring immunization of older children in upper grades as well as those entering college.
The parents of whom our she=elah speaks fear that some or all of the vaccines administered on the required immunization schedule pose unacceptable risks to their children. These risks are not imaginary ones. The Committee on Infectious Diseases of the American Academy of Pediatrics states openly that Aalthough modern immunizing agents are generally considered safe and effective, they are neither completely safe nor completely effective. Some vaccines may have an untoward reaction, and some will not be protected.@ It is hardly a surprise that vaccines may cause Auntoward reactions.@ Medical therapies, many of which carry the potential for harmful side-effects, are inherently risky; as our own tradition so starkly puts it, Athat which heals one patient may kill another.@ Yet this unhappy reality does not mean that we should refuse to go to the doctor or that the practice of medicine is not a mitzvah. Rather, we measure the risks against the benefits offered by the therapy in question. When we do this with respect to vaccines, we find that the risks they pose are far outweighed by the prospect of infection, morbidity and mortality from the diseases they are intended to prevent. For example, each year in the United States, eight to ten people will develop paralytic polio as a result of immunization with the oral polio vaccine (OPV) or through contact with a person who has received that vaccine. This number is tiny compared to the many thousands of cases of polio which occurred each year prior to the development of the first successful vaccine. Another instructive case is that of the whole-cell pertussis vaccine, the subject of great controversy during the late 1970s and early 1980s. Due to claims that some children had been injured by the vaccine, many parents in Japan, Sweden, and the United Kingdom chose not to immunize their children against the disease. The result was a return of pertussis in those countries to epidemic proportions. The risks of the pertussis vaccine are real enough: grave complications (encephalopathy and permanent neurological damage) occur in 1 out of 100,000 and 1 out of 300,000 cases, respectively. Still, the risk of death or encephalopathy from pertussis infection in an unimmunized child is much higher. Projections from the recent epidemics indicate that the risk of pertussis-related death is 10 times greater in an unimmunized population than in an immunized population of children.
The risks associated with immunization are of vital concern to the medical profession and the scientific community, which have developed various means to monitor the safety of vaccines. The American Academy of Pediatrics issues recommendations that attempt to minimize risk by providing specific advice on dose, route, and timing of the vaccine and by delineating circumstances that warrant precaution in, and abstaining from, administering the vaccine. In the United States, the Food and Drug Administration and the Centers for Disease Control and Prevention manage a program called the Vaccine Adverse Event Reporting System (VAERS), which like similar programs in other countries maintains surveillance over vaccine safety. Improved and safer versions of the vaccines are constantly tested and made available. These surveillance and testing measures are not perfect; they do not reduce the risk factor of the vaccines to zero. Yet with all that, Athe overwhelming view of the medical/public health community is that the risks of vaccine reactions, both the common mild reactions and the rare, more serious reactions, are very much outweighed by the public health benefit conferred by current vaccination practices and policies.@
All of this leads to the conclusion that immunization qualifies as refu=ah bedukah or vada=it, a medical therapy of proven effect. As such, Jewish tradition would define immunization as part of the mitzvah of healing and recognize it as a required measure, since we are not entitled to endanger ourselves or the children for whom we are responsible by refusing proven medical treatment. Immunization, moreover, is a matter of social ethics and responsibility as well. Scientists recognize that protection of individuals from serious diseases depends not only on their own immunization but on the immunization of others in the community. Vaccines are not one-hundred percent effective; even in a fully immunized population, the vaccine will not succeed in conferring immunity upon every single person. Our chance of contracting disease is lower, therefore, if those around us remain healthyBthat is, if they are immunizedBthan if they carry the disease. The concept here is Acommunity immunity@ or Aherd immunity,@ the level of immunity achieved when there is a sufficient level of vaccine protection in the population to prevent the spread of the disease to those who remain biologically susceptible. AWith herd immunity, the likelihood of two susceptible individuals being within the range for transmission is very, very small.@ Immunization, therefore, is not a purely private matter but one of social ethics: our decision to vaccinate or not to vaccinate directly affects the lives and health of our neighbors.
For these reasons, we would endorse programs of compulsory immunization in our communities, with exemptions granted to those individuals whose medical conditions place them at particular risk of injury or untoward side effects. Aside from those individual cases, there are no valid Jewish religious grounds to support the refusal to immunize as a general principle.
3. A Note on Scientific Evidence. The preceding section draws heavily upon expressions of scientific opinion, particularly those of researchers associated with the universities, professional societies, governmental agencies and other institutions that comprise the mainstream of the scientific community. As noted above, it is Athe overwhelming view@ of this community that immunizations are both safe and effective. This view has been challenged, however, by critics whose arguments have provoked a controversy that rages in print, on Internet sites, and before government bodies. The critics charge that many of the vaccines currently in use are ineffective or dangerous to the lives and health of children. These criticisms, in turn, are rebutted by the representatives of Athe overwhelming view@ who insist that vaccines prevent disease and that the risks they pose are either non-existent or minimal.
As rabbis, we are not competent to render judgments in scientific controversies. Still, we do not hesitate to adopt Athe overwhelming view@ as our standard of guidance in this and all other issues where science is the determining factor. True, the scientific consensus is not infallible; history teaches us that the Apredominant viewpoint@ among scientists has often been wrong. The conclusions we reach in this responsum would therefore change were we to be convinced that the scientific information on which they are based is faulty. Yet we rely upon Athe overwhelming view@ of scientists, not because scientists are immune to error, but because today=s science is a discipline defined by a rigorous methodology that leads to the recognition and correction of mistakes. The findings of any researcher are tested and retested carefully; they are subject to close scrutiny and peer review. Questions concerning the safety of any vaccine are vigorously examined by the medical community, and these examinations can and do lead to changes in the recommended schedules of vaccines. It is precisely because scientists acknowledge that they can be wrong and precisely because the medical community trains such a watchful eye upon the issue of vaccine safety that Athe overwhelming viewpoint,@ the consensus opinion among practitioners, is worthy of our confidence.
4. May a Congregation Require Immunization as a Requirement for Religious School Admission? Jewish tradition recognizes the right of the community to make legislative enactments made by a community for the maintenance of its vital institutions and the governance of its public affairs. These enactments are called takanot hakahal (Acommunal ordinances@), a concept we have cited as the basis for our own community=s power to determine its destiny and to adopt rules that bind its members. In terms of substance, moreover, the community may adopt any rule it sees fit, even if the rule is not supported by formal Talmudic halakhah, so long as it does not constitute an egregious violation of conscience or a clear religious prohibition. This congregation is therefore entitled to require that its students be immunized against disease prior to their admission to religious school. Such a rule violates no prohibition of Jewish law or tradition. On the contrary: inasmuch as this rule would reinforce a policy of immunization that medical opinion accepts as a vital measure in the battle against life-threatening disease, it reflects our understanding of medicine as a mitzvah and our ethical responsibility to those who live alongside us.
1. Immunization is in the category of refu=ah bedukah or refu=ah vada=it, Aproven@ medicine, and as such is part and parcel of the traditional obligation to practice and to avail ourselves of medical treatment.
2. Because it can create the conditions that lead to Aherd immunity@ or Acommunity immunity,@ compulsory immunization is a vital aspect of the medical policy of society. So long as exemptions to vaccination requirements are granted to those individuals to whom the vaccines pose a particular medical risk, neither Jewish tradition nor our own Reform understanding of that tradition would object to compulsory immunization against disease.
3. A congregation is entitled, should it so choose, to adopt a rule that requires immunization of students before their admission to religious school.
If needed, please consult Abbreviations used in CCAR Responsa.