Zaldy Img Foter.com CC BYFew issues divide libertarians so emphatically as government-mandated vaccinations against communicable diseases, as reason discovered after including anti-vaccine activist Jenny McCarthy in our "45 Enemies of Freedom" list (August/September 2013). That selection brought forth a deluge of mail, such as this succinct riposte from reader Christopher Kent: "Freedom doesn't get much more personal than the right of individuals to choose what is put into their bodies, and to accept or reject medical procedures."
But what happens when one person's individual choice leads to the otherwise preventable infection of another person who chooses differently? How do you assign property rights and responsibilities to an airborne virus? And how far can or should the state intrude into family decisions that affect the safety and health of children? The issue seems almost tailor-made to produce philosophical conflict among those who otherwise share a heightened skepticism of government power.
This is no mere debate-society chum. Over the last 15 years, spurred on by McCarthy and other high-profile advocates who claim that vaccinations may cause such damaging side effects as autism, more parents are opting out of vaccinations for highly contagious diseases for their children. A 2011 survey by the Associated Press reported that exemption levels in eight states now exceed 5 percent.
At the same time, incidence and morbidity of diseases such as whooping cough are back on the rise. reason Science Correspondent Ronald Bailey, who contributes to our forum below, has argued forcefully that the popularization of junk anti-vaccine science, and the resulting increase in opt-outs, has led to scores of needless deaths, thousands of hospitalizations, and tens of thousands of cases of preventable illnesses.
Yet neither vaccines nor the diseases they combat are 100 percent predictable or controllable. Pathogens adapt, hosts develop resistance, unforeseen consequences arise. As Jeffrey Singer, a general surgeon and longtime libertarian activist, points out below, "Not everyone who is vaccinated against a microbe develops immunity to that microbe. Conversely, some unvaccinated people never become infected."
That uncertainty does not stay the government's hand. Currently, all 50 states and the District of Columbia include at least some form of state-mandated vaccinations for young children who are entering school (including all public and most private institutions). The usual diseases targeted include the mumps, measles, rubella, polio, diphtheria, tetanus, pertussis, and varicella (chickenpox). Typically, parents can only opt out after demonstrating a philosophical or religious objection. One of the last official acts of the famously paternalistic former New York City Mayor Michael Bloomberg (who also made our "45 Enemies of Freedom" list) was to make flu shots mandatory for all children under 5 who are enrolled in city-licensed schools or daycare facilities. As clinical physician Sandy Reider makes clear below, government keeps expanding the list of mandatory vaccines. It now often includes diseases, such as hepatitis B, that rarely affect children.
So what is the proper role for government, and the citizenry, in the vaccination of children? The lines are hard to draw; all the more reason to have a reason debate. Below, Bailey, Singer, and Reider take the scalpel to each others' arguments, in the hope of bringing more practical and philosophical clarity to a divisive topic.
Refusing Vaccination Puts Others at Risk
Millions of Americans believe it is perfectly all right to put other people at risk of death and misery. These people are your friends, neighbors, and fellow citizens who refuse to have themselves or their children vaccinated against preventable infectious diseases.
Aside from the issue of child neglect, there would be no argument against allowing people to refuse government-required vaccination if they and their families were the only ones who suffered the consequences of their foolhardiness. But that is not the case in the real world. Let's first take a look at how vaccines have improved health, then consider the role of the state in promoting immunization.
Vaccines are among the most effective health care innovations ever devised. A November 2013 New England Journal of Medicine article, drawing on the University of Pittsburgh's Project Tycho database of infectious disease statistics since 1888, concluded that vaccinations since 1924 have prevented 103 million cases of polio, measles, rubella, mumps, hepatitis A, diphtheria, and pertussis. They have played a substantial role in greatly reducing death and hospitalization rates, as well as the sheer unpleasantness of being hobbled by disease.
A 2007 article in the Journal of the American Medical Association compared the annual average number of cases and resulting deaths of various diseases before the advent of vaccines to those occurring in 2006. Before an effective diphtheria vaccine was developed in the 1930s, for example, the disease infected about 21,000 people in the United States each year, killing 1,800. By 2006 both numbers were zero. Polio, too, went from deadly (16,000 cases, 1,900 deaths) to non-existent after vaccines were rolled out in the 1950s and 1960s. Chickenpox used to infect 4 million kids a year, hospitalize 11,000, and kill 105; within a decade of a vaccine being rolled out in the mid-1990s, infections had dropped to 600,000, resulting in 1,276 hospitalizations and 19 deaths. Similar dramatic results can be found with whooping cough, measles, rubella, and more.
And deaths don't tell the whole story. In the case of rubella, which went from infecting 48,000 people and killing 17 per year, to infecting just 17 and killing zero, there were damaging pass-on effects that no longer exist. Some 2,160 infants born to mothers infected by others were afflicted with congenital rubella syndrome-causing deafness, cloudy corneas, damaged hearts, and stunted intellects-as late as 1965. In 2006 that number was one.
It is certainly true that much of the decline in infectious disease mortality has occurred as a result of improved sanitation and water chlorination. A 2004 study by the Harvard University economist David Cutler and the National Bureau of Economic Research economist Grant Miller estimated that the provision of clean water "was responsible for nearly half of the total mortality reduction in major cities, three-quarters of the infant mortality reduction, and nearly two-thirds of the child mortality reduction." Providing clean water and pasteurized milk resulted in a steep decline in deadly waterborne infectious diseases. Improved nutrition also reduced mortality rates, enabling infants, children, and adults to fight off diseases that would have more likely killed their malnourished ancestors. But it is a simple fact that vaccines are the most effective tool yet devised for preventing contagious airborne diseases.
Vaccines do not always produce immunity, so a percentage of those who took the responsibility to be vaccinated remain vulnerable. Other defenseless people include infants who are too young to be vaccinated and individuals whose immune systems are compromised. In America today, it is estimated that about 10 million people are immuno-compromised through no fault of their own.
This brings us to the important issue of "herd immunity." Herd immunity works when most people in a community are immunized against an illness, greatly reducing the chances that an infected person can pass his microbes along to other susceptible people.
People who refuse vaccination for themselves and their children are free riding off of herd immunity. Even while receiving this benefit, the unvaccinated inflict the negative externality of being possible vectors of disease, threatening those 10 million most vulnerable to contagion.
Vaccines are like fences. Fences keep your neighbor's livestock out of your pastures and yours out of his. Similarly, vaccines separate people's microbes. Anti-vaccination folks are taking advantage of the fact that most people around them have chosen differently, thus acting as a firewall protecting them from disease. But if enough people refuse, that firewall comes down, and innocent people get hurt.
Oliver Wendell Holmes articulated a good libertarian principle when he said, "The right to swing my fist ends where the other man's nose begins." Holmes' observation is particularly salient in the case of whooping cough shots.
Infants cannot be vaccinated against whooping cough (pertussis), so their protection against this dangerous disease depends upon the fact that most of the rest of us are immunized. Unfortunately, as immunization refusals have increased in recent years, so have whooping cough infections. The annual number of pertussis cases fell from 200,000 pre-vaccine to a low of 1,010 in 1976. Last year, the number of reported cases rose to 48,277, the highest since 1955. Eighteen infants died of the disease in 2012, up from just four in 1976.
The trend is affecting other diseases as well. In 2005, an intentionally unvaccinated 17-year-old Indiana girl brought measles back with her from a visit to Romania, and ended up infecting 34 people. Most of them were also intentionally unvaccinated, but a medical technician who had been vaccinated caught the disease as well, and was hospitalized.
Another intentionally unvaccinated 7-year-old boy in San Diego sparked an outbreak of measles in 2008. The kid, who caught the disease in Switzerland, ended up spreading his illness to 11 other children, all of whom were also unvaccinated, putting one infant in the hospital. Forty-eight other children younger than vaccination age had to be quarantined.
Some people object to applying Holmes' aphorism by arguing that aggression can only occur when someone intends to hit someone else; microbes just happen. However, being intentionally unvaccinated against highly contagious airborne diseases is, to extend the metaphor, like walking down a street randomly swinging your fists without warning. You may not hit an innocent bystander, but you've substantially increased the chances. Those harmed by the irresponsibility of the unvaccinated are not being accorded the inherent equal dignity and rights every individual possesses. The autonomy of the unvaccinated is trumping the autonomy of those they put at risk.
As central to libertarian thinking as the non-aggression principle is, there are other tenets that also inform the philosophy. One such is the harm principle, as outlined by John Stuart Mill. In On Liberty, Mill argued that "the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others." Vaccination clearly prevents harm to others.
So what are the best methods for increasing vaccination? Education and the incentives of the market have encouraged many Americans to get themselves and their children immunized, and surely those avenues of persuasion can and should be used more. Perhaps schools and daycare centers and pediatric clinics could attract clients by advertising their refusal to admit unvaccinated kids. Or social pressure might be exercised by parents who insist on assurances from other parents that their children are vaccinated before agreeing to playdates.
But it would be naive not to acknowledge the central role of government mandates in spreading immunization. By requiring that children entering school be vaccinated against many highly contagious diseases, states have greatly benefited the vast majority of Americans.
For the sake of social peace, vaccine opt-out loopholes based on religious and philosophical objections should be maintained. States should, however, amend their vaccine exemption laws to require that people who take advantage of them acknowledge in writing that they know their actions are considered by the medical community to be putting others at risk. This could potentially expose vaccine objectors to legal liability, should their decisions lead to infections that could have been prevented.
In terms of net human freedom, the tradeÂoff is clear: In exchange for punishment-free government requirements that contain opt-out loopholes, humans have freed themselves from hundreds of millions of infections from diseases that maimed and often killed people in recent memory. People who refuse vaccination are asserting that they have a right to "swing" their microbes at other people. That is wrong.
1However, even members of religions that do not prohibit vaccination have attempted to obtain religious exemptions to mandatory vaccinations, with mixed results. Compare Berg v. Glen Cove City Sch. Dist., 853 F.Supp. 651, 655 (E.D.N.Y. 1994) (granting a Jewish parent a religious exemption even though Judaism does not object to vaccination) with Farina v. Bd. of Educ., 116 F.Supp. 2d 503, 508 (S.D.N.Y. 2000) (finding that Catholic parents were not eligible for a religious exemption since their refusal to vaccinate their child was not for religious reasons) and McCarney v. Austin, 293 N.Y.S.2d 188, 200 (N.Y. 1968) (holding that New York’s religious exemption law does not exempt Catholics since the Catholic faith does not prohibit vaccination).
2Unspecified personal reasons make up 95 percent of all mandatory vaccine exemptions granted in the state of Washington .
3The U.S. Supreme Court has held that a state’s interest in promoting public health overrode an individual’s right to opt his or her child out of a vaccine for religious reasons, for “[t]he right to practice religion freely does not include liberty to expose the community or the child to communicable disease or the latter to ill health or death” .
4The percentage needed varies by disease — achieving herd immunity from measles, for instance, would require that 90 percent of a community be immunized .
5Some of the states that have codified such exemptions are Arizona (Ariz. Rev. Stat. Ann. § 15-873), California (Cal. Health & Safety Code § 120365), Idaho (Idaho Code § 39-4802), Louisiana (La. Rev. Stat. Ann. § 17:170(E)), Maine (Me. Rev. Stat. Ann. Tit. 20-A, § 6355), Michigan (Mich. Comp. Laws Ann § 333.9215), Minnesota (Minn. Stat. § 121A.15), Nebraska (Neb. Rev. Stat. § 79-221), North Dakota (N.D. Cent. Code § 23-07-17.1), Ohio (Ohio Rev. Code. Ann § 3313.67.1), Oklahoma (Okla. Stat. Tit. 70 § 1210.192), Vermont (Vt. Stat. Ann. Tit. 18, § 1122), Washington (Wash. Rev. Code. § 28A.210.090) and Wisconsin (Wis. Stat. Ann. § 252.04)
6The only requirement for joining the Congregation of Universal Wisdom is a “customary donation” between $1 and $75 — one does not even have to abandon his or her old religion or adopt any new religious tenants .
7The United States, in addition to possessing a strong respect for freedom and individual rights, is also a highly religious nation . Public opinion polls show that only 17 percent of Americans believe religion has too much influence, with 49 percent believing religion is actively under attack . Since “politicians simply cannot afford to not take political considerations into account when deciding what bills they should support,” it is unlikely that all 48 states with religion exemptions would completely repeal them anytime in the near future .
8Furthermore, the immense benefits of litigating such disputes as class action lawsuits may justify alterations to federal and state rules of civil procedure in order to allow such suits to proceed.
9For instance, Juan Carlos Felix, the head of the National Cervical Cancer Coalition’s medical advisory panel, has stated that he “would like to see it that if you don’t have your HPV vaccine, you can’t start high school” .
10The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention has recommended the vaccine for girls between 11 and 12 years of age .
11One can analogize the HPV vaccine to the hepatitis B vaccine, which has not been terribly effective at reducing incidence of the disease because social conservative opposition has prevented universal vaccination .
12Furthermore, one must also consider that the U.S. Supreme Court has held that an individual’s right to practice his religion freely is subordinate to preventing the spread of communicable disease in a community .
13For example, the state of Texas, which had been set to become the first state in the nation to mandate the HPV vaccine, rescinded its mandate several months after it was announced, due to pressure from social conservative groups .