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Personal Belief Exemption for Vaccine Mandates

There is a spectrum of beliefs that surround vaccination; the range spans from wholly against immunization and enthusiastically for it, with a vast range of hesitancy in between. Some have proposed an alternative vaccine schedule due to fear of too many at one time, while others report objection to how the vaccines are developed. Studies on vaccine hesitancy reveal that there are often numerous reasons why parents could be hesitant to vaccinate their children and that paediatricians should do their best to meet the needs of the families in their care. These sentiments have led to personal belief exemptions, otherwise known as philosophical exemptions. However, as everyone in the community is affected by these policies, and the health of the public depends on vaccination rates, personal belief exemptions should only be allowed for vaccines that have relatively low efficacy and cover relatively mild diseases for the majority of the population.

Diseases do not respect national boundaries and our increasingly global world increases the risk of bringing back diseases once eradicated in the United States. According to Vaccines Work, as of November 14th, 2017, there have been 34,483 cases of measles, 7,660 cases of mumps, 2,124 cases of whooping cough, 17 cases of polio in 2017 alone. The measles vaccine is considered extremely safe and effective, with just one dose of the two dose regimen being up to 93% effective [4].  While it has been nearly eradicated in the United States relative to the pre-vaccine era (which annually averaged three to four million cases), it is still prevalent in other countries and the Center for Disease Control notes international travel as a significant contribution to the continuation of outbreaks in America. Other diseases have a similar story and public health continually stresses the importance of vaccination for these reasons. In 2015, over half of the states (26) did not report meeting a 95% coverage target for the measles, mumps, and rubella (MMR) vaccine. Low coverage rates inhibit herd immunity which protects the individuals who cannot be immunized due to medical reasons and makes it more likely for them to become ill.

Ethical consequences of vaccine mandates are complex. Most of my argument has been that mandates are justified under the principle of justice and the goals of public health; nevertheless, differing pools of ethical theory will dissent. In the United States, autonomy is the most dearly held principle, and most people object to mandates that restrict the individual’s autonomous choice, especially in healthcare where the history of paternalism is widely acknowledged as a detrimental medical model. However, we do not live in a vacuum as individuals; choices that others make affect each person regardless of the value we put in individual rights and choice. Therefore, it is unrealistic and self-centered to only consider the individual’s scope when deciding to object to a mandate that intends to impact the entire community.

However, vaccines also carry a nonzero probability of negative reactions; the DTap vaccine, which covers diphtheria, tetanus, and acellular pertussis carries serious allergic reactions in less than one per million doses, but that one individual is still affected. This leaves room for contention among vaccines that are less efficacious, such as the influenza vaccination. It is much more ethically justified to mandate vaccines that carry little risk to the individual and are highly effective. Additionally, in areas that do have high herd immunity, some individuals see the risk of negative side effects as outweighing the benefit of immunity as their individual risk of the disease is very small. With that frame, the harm principle would advocate to prevent harm from the vaccine rather than to risk it for minimal benefit, since the likelihood of contracting the disease is much smaller. However, the majority of vaccines are extremely safe and these abstract theoretical principles should not outweigh the real-world good vaccines accomplish.

Vaccines are one of the most effective public health initiatives to date. They have nearly eradicated some disease from this country and will continue to impact the spread of disease in a global society. However, as the population forgets the damage those diseases may do, and circulates misleading information about the harms vaccines carry, the rate of objections will rise. The different populations involved have different ethical responsibilities and must consider the impact of their actions on a community-wide scale. Mandating certain vaccines that carry little risk and are effective in preventing diseases that spread rapidly should be without question. Philosophical exemptions are a hindrance to the goals of public health and can be dismissed on the basis of justice and greater good, but still present ethical challenges when banned outright. Exemptions should be considered on a case-by-case basis, only for certain vaccines for which the efficacy is relatively low and the risk of harm to the population is minimal.

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