In 1902, a smallpox outbreak infected thousands of people across the northeastern United States. That year, in Massachusetts alone, 2,314 people were infected, and 284 died. This was not unusual for early-twentieth-century Massachusetts: The smallpox vaccine had been invented more than a century earlier and had markedly reduced the incidence of the disease, but the diminished threat of illness motivated fewer people to opt for vaccination. City officials in Cambridge, noting the growing vulnerability of its citizens, made smallpox vaccines a requirement. Children with proof of medical unfitness for vaccination were the only people exempted; any adult objectors would be fined $5.

Henning Jacobson refused to comply. He was fined, but not forced to be vaccinated; the law did not provide for any intervention in response to noncompliance. Jacobson was not satisfied with avoiding the vaccine, and he protested the fine; he and his son had both reacted badly to earlier vaccines and Jacobson believed he had the right to make his own health care decisions. His case ended up in the Supreme Court, which ruled in favor of the state in Jacobson v. Massachusetts. In the interest of protecting the public health, the court found, states can enact “reasonable regulations” to protect the safety of their inhabitants, whose rights to be “freed from restraint” are not absolute.

Vaccine objections and religion

Jacobson is especially resonant this summer; New York responded to the current measles outbreak by eliminating religious exemptions for vaccinations in June. For more than a century, courts have upheld states’ authority to require vaccines even for religious or philosophical objectors, and it was largely due to expansive vaccination efforts that measles was declared eradicated in the United States in 2000. But 45 states and Washington, D.C., offer religious exemptions. Fifteen states also honor refusals on personal or moral grounds.

States are not obligated to offer religious exemptions. They withdraw them only in response to a serious public health crisis. Perhaps this type of objection is permitted because arguing against religious doctrine is difficult, if not impossible. And given this country’s powerful commitment to personal liberty, it makes sense that many states have opted to recognize the role religion plays in personal health care decisions.

Philosophical concerns and public health

There is less nationwide agreement, however, on the issue raised by Jacobson. Is a personal, nonreligious belief about vaccines grounds for refusal? The 1905 decision—still cited to support restrictions on personal liberty in the interest of promoting public health—is certainly in favor of vaccination, even against philosophical objections. Many in the health care community have the same view. Dr. Stephen G. Baum wrote for The Doctor’s Tablet in May that promoting herd immunity above individual beliefs is “a concept that must continue to hold sway.” And the American Academy of Pediatrics ranked the elimination of all nonmedical exemptions to vaccinating children this year’s top priority, above even safeguarding children’s health amid family separations at the border.

Still, philosophical objections can exempt people from vaccinating their children in 15 states, and combating the concerns that motivate those refusals will be critical for the provision of good care and for the maintenance of herd immunity. This is a complex task in part because personal objections to vaccination are so varied. Vaccine hesitancy can stem from distrust of health care practitioners, of pharmaceutical companies, or of the government—an especially relevant concern, as only 17 percent of Americans reported trust in the federal government this year.

To address all root causes of objection would require a shift in public attitudes toward science, medicine, and public health interventions—a worthy task, but unachievable in the short term. However, there are opportunities for progress. A Washington State law requiring people to speak with doctors before getting a vaccine exemption was associated with a 40 percent reduction in exemptions granted. And sensitivity to the vulnerability of certain populations to misinformation might be critical in preventing events such as the 2011 measles outbreak affecting the Minnesota Somali population, allegedly caused by a series of interventions by Andrew Wakefield, a former British doctor whose debunked research claimed a causal relationship between the measles/mumps/rubella vaccine and autism.

Antivaccination sentiment is not new, nor is it independent of political and social context; there is much we can learn from the conditions behind Jacobson and from the evolution of the vaccination debate since. Health care professionals and patients alike can gain insight from the medical and social history of vaccination as we try to maximize both public health and respect for personal beliefs.

Caroline Castleman bioethics intern who blogs at the Doctor’s Tablet.

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