Injecting Ethics Into Vaccine Mandates

As he sat in church one Sunday morning, observing how a place of worship is the perfect petri dish for measles to spread, pediatrician Joshua Williams thought to himself that “a church is no sanctuary for measles”—nor is it one for COVID-19. Amid forecasts that a coronavirus vaccine could be available by the end of 2020, some health policy experts argue that vaccine mandates are necessary to support public health, research, and confidence in government. Although over half of Americans say they would get vaccinated against COVID-19, 12 percent of Americans still do not trust vaccines even though vaccines have been shown to be safe and effective. Among the vaccine skeptics are those Americans who offer religious reasons for their concerns. In a paper published last year, Williams uses the 2019 measles outbreak as a case study to propose three ways that state laws can balance religious concerns about vaccines with the health threats that communities face from the spread of communicable diseases and viruses. According to the latest data, the annual number of measles cases in the United States has reached its highest level in nearly three decades. The rise in measles and now spread of COVID-19 reveals the challenges that local, state, and federal officials face in their efforts to promote vaccination. In response to the recent measles outbreak, some states ended religious exemptions to mandatory vaccination laws or imposed school attendance bans for unvaccinated children. These actions, state officials argued, were necessary to protect public health and combat the spread of measles. But Williams, a proponent of vaccines, contends that states can do a better job of balancing competing values in vaccine enforcement. He argues that state policies should respond to religious objections to vaccination by expanding education on the benefits of vaccination while demonstrating respect for religious autonomy. Enforcing vaccination mandates with criminal sanctions on noncompliant families, as some states already do for measles, only stigmatizes certain religious groups, Williams argues. Instead, he suggests that vaccine regulation should rely on principles of an ethical concept known as Beloved Community. Beloved Community articulates a vision of society where conflict is inevitable, but laws promote dialogue and justice instead of fear of differences. Although some Beloved Community principles, such as avoiding retribution, could conflict with vaccine policy, Williams asserts that Beloved Community’s general concept can and should inform states’ regulatory approaches to an issue that is fraught with ethical dilemmas. Williams offers three proposals for states to adopt when developing their public health strategies on vaccinations to prevent the spread of communicable diseases. First, he urges policymakers to assess the ease with which individuals can obtain religious exemptions under current regulations. The United States does not have a federal vaccination law, but all states have laws that condition school attendance on whether students have received certain vaccines. Most states, however, provide exemptions for families who assert that vaccination conflicts with their religious beliefs. The majority of exemption laws require parents or guardians only to sign a form to opt out of vaccines. Although such laws provide a great degree of religious autonomy, Williams argues that policymakers should consider the potential costs of exemptions that are too easy to obtain, as vaccine-preventable diseases can have life-threatening implications. Instead, Williams advocates the adoption of exemptions that would require a written statement articulating parents’ religious beliefs, stating the reasons for their objections to vaccines, and providing a signature of a religious leader from their faith. Such a rule would take individuals’ religious beliefs seriously while providing a heightened standard for exemption qualification. In fact, states that have imposed such requirements on exemptions have fewer guardians and parents claiming exemptions and fewer cases of vaccine-preventable diseases, explains Williams. Second, Williams advises state public health officials to enforce vaccination requirements consistently across public schools. In North Dakota, for example, inconsistencies in enforcement at different schools resulted in disparate vaccination rates across the state. In response, North Dakota implemented a rule that allows the state to refrain from funding schools with lax enforcement. That same rule also established local compliance programs and instructed school officials to send letters to families of unvaccinated children. Together, these strategies raised vaccination rates across the state while engaging families at a local level by first promoting vaccination instead of imposing immediate penalties. Finally, Williams encourages officials to enact rules that specifically respond to noncompliant religious communities prior to and during vaccine-preventable disease outbreaks. For example, educational modules for parents before the school year could encourage vaccination while fostering dialogue—a key principle of Beloved Community—Williams asserts. Although parents of certain faiths may never agree to vaccination, Williams advises state officials to engage with religious leaders to attempt proactive measures, such as partnering with state departments of health to identify best practices for outbreak prevention within noncompliant communities. Laws may even need to target specific religious communities that remain largely unvaccinated and therefore experience higher rates of a vaccine-preventable disease, Williams suggests. In New York City, unvaccinated children in Orthodox Jewish communities accounted for most of the cases in the state’s most recent measles outbreak. To curtail the spread of the disease, the New York City Department of Health and Mental Hygiene issued an emergency order in April 2019 mandating unvaccinated residents of neighborhoods with a high Orthodox Jewish population to receive a measles vaccine. The government imposed a violation and a fine on noncompliant individuals and those who could not show evidence of immunity to measles. Williams notes that disease outbreaks can create enduring “cracks” among diverse communities if officials respond with policies that fail to respect religious differences. But he nevertheless expresses support for New York City’s emergency order since, despite its targeting of a specific religious community, the city still tried to adhere to principles of Beloved Community. For example, during the emergency order, city officials collaborated directly with Hasidic leaders to educate Orthodox Jewish communities on the benefits of vaccination and to combat misinformation campaigns. Through partnerships with local leaders and residents, the city eventually rescinded its emergency order and declared an end to the measles epidemic. Williams concludes that inclusive efforts such as New York City’s reveal how Beloved Community concepts can balance ethical conflicts when implementing vaccine regulations—a lesson that may prove valuable today as the world nears an available vaccine against the deadly coronavirus