Posted on April 1, 2019 at 4:52 AM
Written by Alberto Giubilini
Oxford Martin School, Wellcome Centre for Ethics and Humanities, University of Oxford
Following a measles outbreak, Rockland County in New York has enforced a 30 day emergency measure that involves barring unvaccinated children and teenagers from any public place (not just schools, but also restaurants, shopping centres, places of worship, and so on). Parents face up to 6 months in jail and/or a $500 fine if they are found to have allowed their unvaccinated children in public spaces. In fact, this measure resembles quite closely a form of quarantine. Some might think this kind of policy is too extreme. However, I think the problem is that the measure is not extreme enough. It is necessary and justified given the state of emergency, but it is not sufficient as a vaccination policy. Parents can still decide not to vaccinate their children and keep them at home for the 30 days the order will last. Thus, the policy still gives some freedom to parents, who are responsible for the situation, and this freedom comes at the cost of penalizing the children, who are not responsible. We need to contain and to prevent measles cases and measles outbreaks by forcing parents to vaccinate their children, not simply by preventing children from leaving their homes when emergencies arise.
The measure was rendered necessary after an executive order that excluded nearly 6,000 unvaccinated individuals from public schools turned out to be ineffective. 153 cases of measles were confirmed in the area, and a total of 182 cases in New York State since last October.
The outbreak was linked to ultra-Orthodox communities in Rockland County who are opposed to vaccines for religious reasons.
Religious communities are regularly responsible for measles outbreaks. One of the largest measles outbreaks in recent years was among unvaccinated Amish communities in Ohio, where in 2014 383 cases of measles were reported. In the Dutch so called “Bible-belt”, an area populated by Orthodox Calvinists who, among other things, oppose vaccination, after the introduction of the measles vaccine there has been a measles outbreak roughly every 12 years, each one lasting around 1 year, with a total of about 2,500 reported cases. Religious opposition and anti-vaxxers (those who think that vaccines are harmful and not beneficial) are causing a resurgence of measles in the US and in Europe. Also because of the Rockland County outbreak, in 2019 there have already been more cases of measles in the US (314) than in most of the previous 10 entire years, with the exception of 2014, when the Ohio outbreak pushed the numbers up to over 600 cases, and of 2018.
Here is what I take to be a few things the Rockland County’s story teaches us.
IRRESPONSIBLE PARENTS AND IRRESPONSIBLE CITIZENS
Measles is a very dangerous infectious disease. In developed countries, 1 in 5,000 infected individuals die of measles, 1 in 1,000-2,000 develop encephalitis that can result in brain damage, and 1 in 16 develop pneumonia (see here). The combined MMR (measles, mumps, and rubella) vaccine is extremely effective and safe. Getting one’s children vaccinated is a very easy and costless option. Whenever we can prevent harm to others in an easy and costless way, we have a moral obligation to do it. Granted, there are some extremely small, non life-threatening, risks of the MMR vaccine – which are vastly outweighed by their individual and collective benefits. In any case, even such small risks ought to be fairly shared across the population when we pursue an important public good like herd immunity, that is, the condition where enough individuals are vaccinated and therefore the unvaccinated ones enjoy indirect protection. Herd immunity from measles requires 95% vaccination coverage. Individuals who are immunosuppressed or who are too young to be vaccinated are put at risk by the choice of parents who refuse to vaccinate their children. In fact, vaccinated individuals are also at risk, given that no vaccine is 100% effective. Even if arguments for parental autonomy and religious freedom justified parents choosing to put their children’s health and life at risk by sticking to their religious views – something which however is normally not conceded (for instance, courts normally order blood transfusions for children of Jehovah’s Witness who oppose blood transfusions for religious reasons) – they do not justify putting other members of ones’ community at risk and do not justify failing to make one’s fair contribution to a very important public good like herd immunity. In liberal secular societies, there are some basic civic and moral duties that outweigh religious freedom, or freedom of conscience more in general. Parents who choose not to vaccinate their children against measles are irresponsible parents and irresponsible citizens. Having failed to fulfil their moral responsibilities towards their children and towards society, the ultra-Orthodox people who failed to vaccinate their children in Rockland County are morally responsible for the outbreak. Religion is no excuse. They are the ones who should pay the cost for the situation.
THE LEGITIMACY OF USING COERCION IN VACCINATION POLICY
Even when herd immunity against measles can be or in fact is achieved through non-coercive policies, coercion is still justified, and indeed ethically required. Vaccination policies, in particular, need to be and ought to be coercive in order to comply with both safety and ethical requirements. Herd immunity is a very unstable condition and subject to change. It cannot be taken for granted. Actually, history teaches us that vaccines are victims of their own success. Herd immunity makes infectious diseases invisible and people tend to forget how dangerous they are and how important vaccines are. And even when data show that there is herd immunity in a certain area, dangerous pockets of undervaccination can remain, like in the case of the Rockland County outbreak. So there are safety reasons for keeping coercive vaccination policies even when herd immunity exists in a given area. We ought to prevent outbreaks, not wait for them to occur and enforce emergency measures afterwards. And there are reasons of fairness for keeping coercive vaccination policies even when herd immunity exists. The state ought to ensure that everyone makes their fair contribution to important public goods like herd immunity that are extremely valuable for society and that a state has the responsibility to preserve. However, as I said earlier, children should not bear the costs of the irresponsible choices of their parents. A measure like the one implemented in Rockland County, by itself, allows children to be harmed two times: first, parents’ freedom not to vaccinate them puts their health and their life at risk; and second, their parents’ decision not to vaccinate them results in their exclusion from social life and from enjoyment of public spaces. This is not ethically acceptable. Even if the emergency situation rendered the policy necessary, simply addressing emergencies is not sufficient, from an ethical point of view. There should be coercive policies in place not only to contain, but also to prevent such emergencies. The penalty for non-vaccination should be on parents, and should be high enough to constitute a strong enough disincentive from refusing vaccination. Of course, exceptions will have to be made for those for whom vaccination is medically contraindicated.
KEEP RELIGION OUT OF PUBLIC HEALTH POLICY
A rabbi of a Jewish community of Rockland County is worried that the policy would lead to discrimination against ultra-Orthodox Jews. It is not clear what he means by ‘discrimination’ here, but it is important to point out that the policy itself is not discriminatory in the negative sense of the term (that is, in the sense of unfairly targeting a certain group). The policy targets any non-vaccinated child. And the coercive policies to prevent measles outbreaks I mentioned above would also apply to any non-vaccinating parent. If members of a community do not comply with public health requirements that are ethically justified in liberal secular societies and expect not to suffer the consequences of non-compliance, they are claiming a privileged status, and preventing people from enjoying a privileged status is not a form of discrimination (in the negative sense of the term). Appeals to religious discrimination to oppose such coercive policies are not only misplaced and unjustified, but also irresponsible, as they give people motivations to resist such policies. In liberal secular societies, people are not entitled to put religion above the public good.
A few days ago a child died in Italy because his parents had him circumcised at home without medical supervision, claiming that they were merely following the Bible’s teaching and that God appeared to the father in a dream urging him to circumcise the child. As the father declared: “If my child died, it is because God called him. It is not my fault: I just did what God, through the Bible, asked me to do to be a good Christian”. Obviously, the parents are now under investigation with the charge of ‘culpable homicide’. Parents who do not vaccinate their children against measles are not acting less wrongly, considering how dangerous measles is for a child. Actually, these parents are acting even more wrongly, since they put in danger not only their children, but also other vulnerable members of their community, including those who are not responsible for such vulnerability (e.g. those who cannot be vaccinated for medical reasons or because are too young).
According to reports, the rate of immunisation in the religious communities of Rockland County is only about 50%-60%, which is very low. These religious communities pose a threat to the population, and religion or religious freedom are no justification for such threats. According to the same reports, in the case of Rockland County health inspectors encountered resistance from local residents of religious communities. A common response they received when visiting the homes of infected individuals as part of their investigations was along the lines of ‘We’re not discussing this, do not come back’. This kind of resistance is not only irresponsible and ethically unjustifiable, but something that a secular and liberal society should not tolerate when important values and important goods, such as fairness and harm prevention, are at stake.