Three Shots at Prevention: The HPV Vaccine and the Politics of Medicine's Simple Solutions

Chapter Eleven. Nonmedical Exemptions to Mandatory Vaccination: Personal Belief, Public Policy, and the Ethics of Refusal

chapter eleven Nonmedical Exemptions to Mandatory Vaccination Personal Belief, Public Policy, and the Ethics of Refusal Nancy Berlinger and Alison Jost Do “good” parents refuse to vaccinate their children? Should policymakers allow parents to opt out of having their children vaccinated based on the parents’ personal beliefs about the safety of vaccination, even if there is no scientific evidence to support these beliefs? Continuing battles between public health experts and parents who question the safety of childhood vaccinations have raised concern over the growing practice of invoking nonmedical exemptions to mandatory vaccinations. These optout provisions, like “conscience clauses” for health care providers, are written into the laws of most states. Several state legislatures are now considering separate nonmedical exemption policies for the human papillomavirus vaccine. The introduction of the HPV vaccine offers an opportunity to examine the tension between the public health goals of mandatory childhood vaccinations and the argument that individuals’ beliefs about science are valid grounds for exemption from public health obligations. Because the HPV vaccine serves different goals than other mandatory vaccinations—it aims to protect the individual who receives it, rather than the communal “herd,” and one of its benefits is cancer prevention—the story of its introduction and uptake also offers an opportunity Nonmedical Exemptions to Mandatory Vaccination 197 to examine the ethics of responsibility from a different perspective. When “strengthening the herd” is not the primary aim of the social contract associated with participation in vaccination, do parents still have an obligation to protect their adolescent daughters from a sexually transmitted disease they may someday be exposed to? (And if so, what about protecting their sons from HPV-related cancers and other diseases affecting men?) Has the HPVvaccination story, as it has played out in the American media over the past few years, had a different ending than we expected, based on what parents decided to believe, and to do, once this vaccine was introduced? Did “cancer” trump “conscience”? Medical and Nonmedical Exemptions to Routine Childhood Vaccinations School immunization laws in every state permit medical exemptions for children whose underlying health conditions, such as HIV infection, cancer, or immunosuppressive therapies, place them at undue risk from one or more routine immunizations.1 Forty-eight states also permit “nonmedical” exemptions based on religious convictions, although most religions do not take a position on vaccination: Christian Science and other faith-healing traditions are among the few recognized religions in which immunization refusal might be construed as the expression of a religious belief. Twenty of these forty-eight states also permit nonmedical exemptions based on nonreligious personal beliefs.2 States vary in the language used to describe the basis for a nonmedical exemption and in the standards of proof required of parents. (In the interest of clarity and consistency , this essay uses the phrase religious conviction when referring to laws, policies, and practices that explicitly concern adherence to religious doctrine, and personal belief when referring to laws, policies, and practices that concern beliefs about science that are not necessarily religious in nature.) In some states, parents have been required to defend their requests at a “religious sincerity” hearing or to provide written documentation that their religious convictions or personal beliefs are incompatible with state law. In other states, they simply sign a form or check off a box to claim a nonmedical exemption . This is an active area of legislation, with recent legislative trends moving toward adding nonmedical exemption categories or making it easier for parents to obtain such exemptions.3 States where it is easy to get a nonmedical exemption tend to have the largest numbers of such exemptions.4 198 Focus on the Family The HPV Vaccine in the Context of Nonmedical Exemptions The introduction of the HPV vaccine Gardasil, which reduces the risk of cervical cancer by blocking cancer-causing viral strains, has added a new dimension to debates about nonmedical exemptions.5 Since 2006, when the national Advisory Committee on Immunization Practices recommended that the HPV vaccine should be routine for girls by age 12, virtually every state legislature has proposed bills addressing whether Gardasil should become a mandatory vaccine, who should pay for it, how parents should be educated about the risks and benefits of Gardasil, and how exemptions should be handled. Unlike other routine childhood immunizations, which protect against diseases that are communicable through everyday contact, Gardasil provides protection against a common sexually transmitted disease. Even though all but...