Irresponsible Parents, Religious Beliefs, and Coercion. What the Rockland County Measles Outbreak Response Teaches Us About Vaccination Policies

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.

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7 Responses to Irresponsible Parents, Religious Beliefs, and Coercion. What the Rockland County Measles Outbreak Response Teaches Us About Vaccination Policies

  • Keith Tayler says:

    I agree that all children should be vaccinated but I am somewhat concerned by your approach at resolving the problem. You use ‘liberal secular society’ on numerous occasions and claim that it ‘should not tolerate’ non-compliance. As a very vocal atheist living in a predominately liberal secular society, I tend to avoid intolerance when dealing with theists because I believe in reasoned discourse, compromise and consensus. Obviously such an approach does not always work and we may eventually have to try to reach a consensus about minim levels of enforcement.

    The news reports you cite are very sketchy and it would be absurd to use them to understand what are the actual vaccination statistics, differences among communities across the Rockland County, the reasons for the seemingly low vaccination take-up, etc.. According to the BBC report you cite: ‘Skriloff [local newspaper reporter] said that the authorities had been making “steady progress” in encouraging religious communities to immunise children but communication had broken down in the last month.’ Given there is nothing in Jewish scripture that would clearly prohibit vaccination, we should be asking more about this brake down in communication. For example, the problem might be misinformation from the anti-vaccine lobby spreading unchallenged throughout a relatively small closed community. We should also not forget that President Donald Trump has on numerous occasions claimed that Autism is linked to the MMR vaccine. Whether we like it or not, there are many Americans who believe in the authority of their leader and what he says on issues like vaccines. It has never been acceptable to be intolerant in the defence of the values of a liberal secular society without firstly fully exploring every other alternative to reach agreement. Today this task is even more difficult because power has shifted towards intolerance which is, I believe, not a ground we should also seek to occupy.

    • Alberto Giubilini says:

      Thank you for your comment. I agree that reasoned discourse should always be pursued (though I am more skeptical about ‘compromise’ in certain cases: what would a compromise look like in this case? The point is that children either are vaccinated or are not, and my argument is that they ought). However, reasoned discourse should be based on public reason, that is (among other things), on secular arguments about our moral duties and about what legal obligations there should be. If members of these communities are prepared to engage in this kind of discourse, of course I agree that we should listen to them. But at this level of discourse, you’d need an argument (not based on religious premises) against my argument that vaccination should be compulsory, which is based on a harm principle and on a fairness requirement. I am happy to consider any such counterargument or objection to my argument, but so far I have not come across any strong one, based on public reason (including appeals to religious freedom). Also, importantly, coercion does not rule out other measures, such as information campaigns or attempts to have a dialogue with those who oppose vaccines (though there is some evidence suggesting these things do not really work).
      Misinformation and the anti-vax movement (or Donald Trump’s embarrassing claims) do contribute to the problem, as you rightly say, but I think that that is a different problem from the one I have addressed here, which is more specifically about religion-based opposition, although often anti-vaxxers or even those who are simply opposed to mandatory vaccination have ideological views that verge on religion. It is not that these religious people think that vaccines are unsafe or ineffective, from a medical point of view. And it is not a problem of ‘fake news’ about vaccines. The solution might be (and I think it is) the same in both cases, namely coercion. But the reasons for opposing vaccination are different in the two cases (religious in one case, misinformation in the other) and I don’t think anti-vaxxers are responsible for this kind of religious opposition.
      Whether anything in the Jewish Scriptures or in certain Jewish traditions prohibits vaccination is a matter of internal religious doctrine that is not really relevant for the purpose of policy making. Members of those communities would need to internally address that issue, if they so wish. But whatever the ‘correct’ doctrine is from their point of view, policy making should be based on public reason to justify public health policy (or indeed any policy).

  • Keith Tayler says:

    Thanks for your reply. You say, ‘policy making should be based on public reason to justify health policy (or indeed any policy).’ This community must be included in the ‘public reason’ which must, I would contend contrary to your view, take some account of their internal religious doctrine and has some relevance for the purpose of policy making. Of course it may not be possible to reach a consensus and we might have to try to agree the lightest possible but still effective enforcement. The restrictions that have been imposed may be justified because communication has broken down and there is an immediate possibility of harm to others. Nonetheless, given the very limited reliable information we have about this dispute, it is difficult and probably damaging to reasoned discourse to speculate why a significant minority of the community are rejecting vaccination. Indeed, the fact that it is a minority is evidence that there is a dispute or at least disagreement within the community, which gives us some reason to believe the issue could be resolved if the majority “reason” could be further advanced.

    I could be wrong because my (and your) knowledge and understanding of this community is too limited to make any sensible judgements. I find it difficult to accept that you can confidently reject ‘fake news’ about vaccines as being a contributing factor in the decision-making of this minority. Having spent many decades arguing with theists, I can assure you they are extremely adept at using science and pseudo-science in support of their belief systems. You may be right, but without a great deal more information it is unreasonable and, in the present political climate, dangerous to treat this community as “other” because a minority of them are refusing vaccines.

    • Alberto Giubilini says:

      I don’t think that religious doctrine should be taken into account or the purpose of policy making. You can promote religious freedom (which is a secular principle: historically religions have not been very tolerant of other religions), but only when it does not clash with important social values and public goods, which is not the case here (since vaccine refusal clashes with fairness and/or with the harm principle). Wide public consensus is desirable but not necessary for public policy, and in any case does not need to precede coercive measures (it can be built afterwards).
      It is not very clear to me what additional information you think we would need in this case. We know that these communities significantly contributed to the outbreak, that previous milder policies did not work, and that they refuse to cooperate. We know how dangerous measles is and how many cases there have been. I also don’t think that it is very relevant that those who refuse vaccination within that community might be a minority (not a tiny one though, since around 50% of them are not vaccinated). It seems we have a lot of information about what is going on. And the information we miss – about what really drives these people’s refusal, whether religious beliefs, sense of community, anti-vaxxers’ influence – is not really relevant to a justification of coercion based on public reason, it seems to. It is relevant when it comes to ensuring compliance, as different strategies might work differently, depending on what drives resistance. So it is important to understand what drives vaccine refusal and, if possible at all, to build a dialogue with those who refuse vaccination. But it seems this is not always possible, unfortunately.

  • Keith Tayler says:

    I would prefer to live in a world without religion, but the simple fact is religion is still with us and we all live in countries throughout the world where religion – to a greater or less extent – still shapes much of society and directly or indirectly guides policy making. I do my small bit to contain and diminish the influence of religion and other belief systems I believe not to be conducive to my and the public good. But, if I am to adhere to my understanding of reason and the role it should play in social cohesion and values, I think we must continue to take some account of religion in policy making. This might of course be quite negative in that it could limit religious freedom. For example, it is not going to happen in my lifetime, but I would like to get religion out of schools.

    It is interesting that your account of the information we have been given does not chime with mine. You say that the immunisation rate is ‘around 50%’ and the BBC reports that Mr Skriloff said it is ‘about 50%-60%’. Okay, I am a bit funicity when it comes to stats, but if Mr Skriloff or one or two other people in the reporting chain did what you did, we might be looking at an actual figure around 70%. Now although this is not sufficient it, or whatever the figure is might be, is open to further statistical analysis. It is of course relevant that those not vaccinating are in the minority. From an epidemiological perspective this is a minority of a minority of the population which is both good and bad news. (Immunisation rates in a minority might safely be able to fall below full population rates, although this can only be determined with full knowledge of the populations and demographics.) That aside, surely we should try to understand why the majority is behaving differently than the minority and try to get the former to convince the latter to vaccinate. Could this be why the community has been deemed as being uncooperative? Have the authorities been speaking and disagreeing with the non-vaccine minority when they should have been ‘cooperating’ with the majority?

    I fully accept that some emergency measures are in order to contain the disease. My concern is your use of so-called ‘public reason’ which appears to exclude a significant proportion of the public and/or would not be acceptable or justifiable to ‘all’ those persons over whom the rules have authority. I agree with Jürgen Habermas that some issues like abortion (or perhaps as in this case vaccines) may be beyond any reasonable consensus. But we cannot simply justify coercion in the name of ‘public reason’ without if possible first engaging in meaningful discourse.

  • Gabrielle Deakin says:

    Thank you for both the interesting article and the equally interesting comment thread. I am somewhat ashamed to confess to having given some credence, years ago when my children were born, to the anti-vaccine lobby. In the end, I had both of my children fully vaccinated… and possibly the process by which my fears about vaccines were resolved is of some interest to the discussion.

    In the first place, it is interesting to see where and why I acquired these fears. I am Australian, but I live in Spain. When I was pregnant with my first child, it became clear early on that childbirth in a Spanish hospital in the early 90s would be akin to my mother’s experience in the mid sixties–pubic shaving, enema, episiotomy. My friends in Australia had access to a more wholesome experience, which was not resulting in mass infant or maternal death. WHO information supported less invasive approaches to childbirth in the scenario I inhabited (26 years old, no complications during pregnancy)… yet my tentative attempts to negotiate the possibility of a natural birth with my doctor were met with thinly veiled scorn: “oh, you’ve been reading! Well I’ve actually delivered hundreds of babies.”

    Hmm. With trepidation, I investigated the alternative world of midwife assisted home birth and my son was, indeed, born at home, a wonderful and memorable experience. Once one has a direct, personal experience of an episiotomy free labour without the dreadful tear one has been assured by one’s doctor must occur, the possibility that your doctor is wrong, out-of-date, informed by personal prejudices etc feels very real. And once one finds oneself in a community of seemingly likeminded people (i.e. the home birth crowd) it is easy for other ideas that circulate there (vaccines are bad) to benefit from that same atmosphere of distrust in the medical orthodoxy.

    When I expressed concern about vaccines to doctors, their response was that same thinly veiled scorn. I initially decided to administer to my son the minimum of “tried and proven” vaccines, and withhold the newer ones, especially the MMR vaccine which receives particularly bad press in anti-vaccination circles. But
    fairly early on, a lovely child health nurse sat me down and said “yes, there are indeed some rare cases in which a vaccine has some tragic, untoward side-effect, but look at the global picture… and I can assure you that when a child is in danger of dying from an infectious disease, all parents will let you, beg you, to give them any possible solution modern medicine has, no matter what their religious views or nature bias might be”.

    Her dialogued approach, which engaged with the root fear (my child might be damaged) by reminding me of those forgotten times in which many, many more children died or were seriously damaged by infectious disease…while simultaneously acknowledging the existence of those rare anecdotal cases which form much of the basis of the anti-vaccination lobby’s credibility, was decisive. I had, after all, chosen to “put my child at risk” in a statistically minimal way by having a home birth.

    Because vaccinated immunity isn’t quite the same thing as the acquired immunity of having survived the actual disease, because the one baby who falls into a coma after vaccination has immense emotional power (and I do know a couple who lost their first child this way, about 10 years ago–and they have vaccinated their 2nd child!), some degree of speculation on the less-than-perfect nature of vaccines is inevitable… and it seems to me imperitive for the medical community to actively engage with it. If the official line is vaccines 100%, vaccine skeptics 0%, seen often in brouchures for parents, it comes across as propaganda, to those in the grip of anti-vaccination arguments. A vaccines 90%, skeptics, 10% approach might conceivably increase vaccination intake in areas affected by low vaccination rates.

    After all, nowadays, one cannot take the simplest medicine without being provided with a prospectus of possible side-effects, which often include coma, death, lasting neurological damage… We continue to dose ourselves with these medicines, on the understanding that the chances that we we be one of these cases is statistically slim.

    I think the most effective use of coertion is when one fear is pitted against another… What about the following scenario: if you do not vaccinate your child against those infectious diseases which medicine can control, fine, but in doing so understand that you are chosing to renounce for yourself (not your child) medical coverage for all infectious illness. Weighing up these risks would surely lead people to engage more fully with the broader issues of community ethics, and the incompatibility of seeing medical treatment as a right, but medical protocol as an imposition.

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