Regarding immunizations for children who will be attending day (Jewish or parochial) schools: What is the Jewish view on whether this is obligatory or optional? What Jewish values or ethics are involved in this question?
A similar question to the one posed, is whether a Jewish day school has the right to refuse admission to children who are not vaccinated. That question was posed to Jewish scholars and rabbinical students in regard to two essentially identical real-life situations of which I am aware. At least three comprehensive professional responses from an array of denominations exist. (Bibliography is listed at the end of this piece.) To summarize for those who wish a quick answer, all three groups, using Jewish scholarly research, found the school to absolutely have such a right and an obligation to a) the law of the land (state requirements), b) the principles of the mitzvah known as pikuach nefesh, saving lives, as many as possible.
Why have these questions been arising with greater frequency in our times?
Several years ago a British lawyer fashioned a campaign against vaccines that attributed autism spectrum disorders to vaccination via a hypothetical, never substantiated link to mercury. This fraud netted him over a million dollars in “expert” testimony. Children and adults have died for lack of immunity to devastating childhood diseases because many well-intentioned parents disseminated his position and that led some parents to refrain from having their children vaccinated. When their children contract one of these diseases, the lives and well-being of all who come in contact with them are placed in jeopardy.
Judaism, across the board, within every denomination, aspires to life for those born into this world. In Deuteronomy (Devarim) 4:15 we learn: V'nishmartem m'ode l'nafshoteikhem, “Greatly guard your souls,” which has long been read in Jewish bioethics as a duty to protect ourselves from disease. Reb Nachman of Breslov, who died in 1810 of tuberculosis long before treatment and a vaccine had been identified in the second half of the twentieth century, wrote: “One must be very very careful about the health of children...One must inoculate every baby against smallpox before one-fourth (3 months) of the year, because if not, it is like spilling blood (murder).” (Kuntres Hanhagot Yesharot)
Small pox prevention was developed in India, some say, as far back as the year 1000. The best documentation for small pox prevention is 15th Century Chinese documents which record an ability to decrease mortality from 20-30% due to small pox, down to 0.5-2% through techniques directly related those that create the vast life-saving human "herd immunity" in place today. While many diseases remain to be conquered, the World Health Organization, established a world-wide vaccination that by 1980, eliminated small pox, a devastating disease that killed and maimed for generations.
Not only an answer, also a process is needed when it comes to addressing an answer to a bioethics question. By way of responding to the question, it would be appropriate for the school to respond to parent concern by validating that their feelings of concern and activism are appreciated by the administration. Even though their proposals regarding vaccines cannot be adopted under Jewish bioethics and under most legal systems, all people deserve to be listened to patiently when expressing ideas and concerns, we never know when a person is bringing something that is new information to our attention. It is also helpful to establish a series of educational programs about vaccines to help facilitate comfort with the requirement. It is helpful to subject articles from the popular or medical press provided by parents to the same rigorous scrutiny and discussion that we bring to Jewish sacred text, and to encourage the mitzvah of funding vaccine research.
Sources drawn upon in order to come to the position of the three panels regarding vaccinations and schools include the Shulchan Aruch, the code of Jewish law, which also weighs in heavily in favor of preventive medicine: “it is a positive commandment (mitzvah aseh) to remove anything that could endanger life, and to safeguard against any of these things, and to be very careful, to guard yourself and guard your soul. Someone who does not remove that which is potentially dangerous will have set aside this positive mitzvah." (Choshen Mishpat 427: 8-10)
The Shulchan Aruch citation continues by asking: “What of one who indicates: 'I am willing to endanger myself, why should this matter to anyone else?...or whoever is careless about these issues, is given lashes by the Beit Din (Jewish court) and whoever takes care to avoid them is considered praiseworthy.'” While we no longer whip offenders, the emphasis on not endangering others is explicated clearly here. Further, we learn in the Bible, Leviticus 19:16: “Do not stand aside while your neighbor's blood is shed” and in the Shulchan Aruch Choshen Mishpat 426 the commentator adds: “Do not abandon your neighbor when [s]he is in danger.”
The Rambam in Mishna Torah Hilchot Deot 4:1 teaches that God wishes us to remain healthy because it is impossible to integrate the teachings when we are ill, therefore one must remove anything that causes one harm, and work to bring good health. Parental responsibilities are detailed in a number of our sacred texts. For example, the Ralbag on Proverbs in Chapter 23 offers an essay on parenting which emphasizes the parental role in teaching safe living practices in order to avoid addictions, diseases, and obesity.
Sadly, we have not yet achieved sufficient levels of immunization in our world to create the level of human world-wide immunity that might also wipe out a great many more major, life-threatening diseases. It is clearly vital to participate in immunization programs to bring us to that virtually messianic day. Here is some sobering data, if you are still not on-board with the decision of the majority of Jewish scholars:
Unicef Estimate of Deaths due to vaccine-preventable diseases 2008:
Total number of children who died from diseases preventable by vaccines currently recommended by WHO, plus diseases for which vaccines are expected soon: 2.5 million.
Hepatitis B: 600 000
Hib: 363 000
Pertussis: 254 000
Tetanus: 163 000
Other (polio, diphtheria, yellow fever): 36 000
Estimated number of deaths in children under five from diseases preventable by vaccines (excluding measles) currently recommended by WHO: 890 000.
Hib: 363 000
Pertussis: 254 000
Neonatal tetanus: 128 000
Tetanus (non-neonatal): 16 000
Other (polioa, diphtheriaa, yellow fever): 19 000.
Estimated number of deaths in children under five due to rotavirus and pneumococcus: 1.3 million.
Pneumococcal disease: 735 000
Rotavirus: 527 000
May your life, and your children and grandchildren's lives, be healthy and blessed and your actions be a blessing for others.
Teshuvah of 2004 by Rabbi Joseph Prouser for the Committee on Jewish Law and Standards of the Conservative Movement
Teshuvah of 1999, the Reform Movement’s Central Conference of American Rabbis’ Responsa 5759.10
Teshuva of Fall Semester 2009, by the Bioethics, Halachah and the Role of the Rabbi course taught by Rabbi Goldie Milgram for the ALEPH Ordination Program.
I am neither an expert in medicine nor in public health policy. It seems to me that from a Jewish perspective there are two approaches to your question. The first is the notion of dina de-malchuta dina (the law of the land is law). According to this principle, Halachah (Jewish law) recognizes the validity and authority of civil law as determined by the governmental authorities. One example of this is that Halachah requires an individual to obey traffic laws even though there is zero discussion of speed limits in any of the traditional Jewish sources. There is a vast literature on the details and parameters of dina de-malchuta dina which leads to many interesting questions and conversations on the separation (or lack thereof) of church and state from a Jewish perspective. Most authorities agree that dina de-malchuta dina can never be used to require a Jew to act against Halachah, but it can be invoked for areas in which Halachah is silent. It is very possible that the notion of dina de-malchuta dina would obligate an individual to comply with the immunization policy enacted by local governments and/or school boards. Additionally, a school has the right to refuse admission to any student who does not comply with the school’s policies. Assuming the school requires its students to be immunized, the school can decide not to admit a student who is not immunized.
The second approach is more internal and is the question of whether Halachah weighs in on the question of immunization and public health policy. While these are contemporary concepts, there is no explicit discussion in any of the classical sources, and most Jewish authorities who grapple with issue rely on building analogies and comparisons to cases discussed in traditional sources.
In recounting the Jewish people’s experience at Mt. Sinai, Moses implores the people: Only take heed to thyself, and keep thy soul diligently, lest thou forget the things which thine eyes saw, and lest they depart from thy heart all the days of thy life; but make them known unto thy children and thy children's children; (Deuteronomy 4:9). In the same passage he also warns the people against idolatry by saying: Take ye therefore good heed unto yourselves--for ye saw no manner of form on the day that HaShem spoke unto you in Horeb out of the midst of the fire(4:15). Though clearly taken out of their original context the phrases that are bolded have been understood in Halachic literature to be the basis for an obligation to safeguard one’s health. Later authorities argue whether this should be categorized as a positive or negative commandment. If it is a negative commandment, then all it requires is that one simply stays out of danger. If it is a positive commandment then one must take proactive measures to protect one’s health. In two places Maimonides (who in addition to being a great Jewish legalist and philosopher was a renowned physician) indicates that it is a positive commandment (Hilchot De’ot 4:2; Rotzei’ach 11:4).
The overwhelming consensus in the medical community is that immunization is a necessary and simple step to prevent the spread of disease. Certainly if one takes the approach that there is a positive commandment to proactively safeguard one’s health, it seems to me that immunization is a necessary measure. In the context of this debate one also hears the argument that it is selfish to not immunize because of the potential threat this poses to others. An analogy may be built to discussions in the Talmud of one who places a hazardous item in the public thoroughfare. Such a person is negligent for any damages caused.
As a final thought, there are those who undoubtedly will refuse to immunize their children. I am reminded of the Gemara’s discussion of the verse from Psalms 116:6 The Lord protects the foolish/simple. The Gemara (Shabbat 129b) understands this to mean that if there is a danger that the public is not generally concerned about, it is not prohibited based on our verse. Rabbi Moses Feinstein famously applied this discussion to the question of whether Halachah prohibits smoking. He said that one may not begin smoking but if one is already a smoker they need not stop based on the verse The Lord protects the foolish/simple.
The Jewish view regarding immunizations for children at either Jewish day or parochial schools is one of obligation on the part of the parent to do so. The Jewish tradition considers fulfilling this obligation under and number of precepts which pertain to: The health and safety of the child, the health and safety of the community at large, the need for preventative health care and abiding by the law of the land. (All extensively addressed in Rabbi Joseph Prouser’s teshuvah, Jewish legal ruling, on this matter for the Conservative movement’s Committee on Jewish Law and Standards)
The Book of Proverbs (23:12-13) points out, “Devote your heart to instruction, your ears to words of knowledge: Do not withhold corrective measures from your child. Rabbi Prouser directs us to Gersonides (14th century) comment to, “Protect your child, that he may not suffer physical death prematurely, and so that the part of him which allows him to attain eternal life, not die.” Ibn Ezra’s (12th century) point is similar: “Intervene so that the soul not die with the death of the body, and intervene so that your child not die before their appointed time.”
The Babylonian Talmud (tractate Kiddushin, page 29A) also points out certain obligations of the parent towards their child. One specifically noted is to teach them “how to swim”. The Talmud considers this with the thought in mind that if the child travels by boat, which subsequently begins to sink, the child would find themselves in danger if they did not know how to swim. This idea is focused by the standard that it is, k’fi tsrihan bilvad, “strictly on the basis of the children’s needs,” not the means or discretion of the parent. Commenting on this Rabbi Samson Raphael Hirsch teaches that this is an obligation on the parent to “watch carefully over his [the child’s] health. Protect him as far as lies in human power from sickness and deformity.
The obligations to participate in preventative health care in addition to abiding by the Halakhic concept that, “law of the land is the law” (dina d’malchutah dina) has much support within the Jewish tradition. Two such pieces of support can be found in both positive and negative commandments: “Take utmost care and watch yourselves scrupulously” (Deuteronomy 4:9) and “You shall not bring blood upon your house.” (Deuteronomy 22:8). Rabbi Elliot Dorff also offers that, “It would be a violation of Jewish law… for a Jew to refuse to be inoculated against a disease, at least where the inoculation has a proven track record of effectiveness. Jews, to the contrary, have a positive duty to have themselves and their children inoculated against all diseases where the preventive measure is effective and available.”
Prouser notes that participating in school mandated immunization programs helps achieve “herd immunity” which is also related to the biblical command to, “not stand idly by the blood of your neighbor”. If the law of the town, city, state, region, or country obligates participation in the program without obvious risk, we are obligated to abide. In some ways the Jewish tradition considers vaccinations a form of pikuah nefesh (saving a life). In doing so Rabbi Shlomo Zalman Auerbach ruled that it is even permissible to “set aside Shabbat in order to receive an immunization, if foregoing the Sabbath opportunity would necessitate an unacceptable delay, thus creating a potentially life-threatening situation.”
In his teshuvah Rabbi Prouser concludes, “Timely administration of vaccines with a proven record of effectiveness and safety is ‘a basic and necessary requirement for appropriate pediatric care.’ Unless medically contraindicated for specific children, in extraordinary and compelling cases, parents have an unambiguous religious obligation to have their children immunized against infectious disease. By effectively removing their children as potential sources of contagion, and simultaneously contributing to “herd immunity,” parents fulfill a related religious obligation to remove hazardous conditions which imperil the public’s health and safety. Failure to immunize children against vaccine-preventable disease is a serious, compound violation of Jewish Law: there is no basis in Halakhah to support a parent’s request for a religious exemption from state-mandated immunizations.”
I’m afraid I can’t give you the Jewish view on this question, because there will be more than one “Jewish view.” The answer requires that we balance a number of competing concerns, and since different people will balance those concerns in different ways, their conclusions will vary.
But I can give you an example of how one group of rabbis worked to formulate an answer to this very question. I am referring to the Responsa Committee of the Central Conference of American Rabbis (CCAR), the association of Reform Rabbis. In 1999, the committee was asked about a congregation’s policy to require certain immunizations before children would be allowed to attend the congregational school. Some parents, who regarded immunization as excessively risky, refused to have their children immunized and challenged the policy. The congregation wanted to know whether its policy was “correct and justifiable according to Jewish tradition.”
In its responsum (opinion; teshuvah), the committee answered “yes.” In arguing for its conclusion, the responsum makes several points. First, Jewish law defines the practice of medicine as a mitzvah, an act that enables us to fulfill the obligation of pikuach nefesh (the preservation of human life), which our tradition regards as perhaps the greatest mitzvah of all. Second, immunization has become accepted the world over as an integral and vital element in the practice of medicine. As with any other medical procedure, there are indeed risks involved with immunization. But the responsum found that: a) these risks are far outweighed by the benefits that immunization provides; b) the scientific community has established effective programs to supervise vaccine safety; and c) by refusing to immunize their children, parents endanger not only the health of those children but of other members of the community who remain susceptible to the disease even after they have been immunized. For all these reasons, the responsum concluded that a congregation or school is well within its rights to adopt a compulsory immunization policy.
Third, the responsum insists upon the value of following scientific procedures in questions of this nature. Scientists, as we know, are not perfect, and the conclusions drawn by science at any particular stage of history may well be overturned on the basis of further research. But that’s just it: the scientific community derives knowledge through research, a discipline that tests the findings of individual researchers and helps uncover and correct mistakes. When the overwhelming consensus in the scientific community holds that immunization prevents deadly diseases and that the risks of immunization are either nonexistent or minimal, that consensus is worthy of our confidence.
For a more expansive discussion of all these points, along with the traditional texts upon which the conclusion is based, please see Reform Responsa for the Twenty-First Century (New York: CCAR, 2010), vol. 1, no. 5759.10, pp. 107=120.
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