Sunday’s New York Times had one of those “room for debate” features that feature short essays by a group of people on a single topic, but this one is of special interest to science and woo hounds. The topic was “Making vaccination mandatory for all children,” and four people weigh in with divergent opinions. Surprisingly, only one one favors mandatory vaccination for all, and another—the former Surgeon General of the U.S.—favors mandatory vaccination except for those with religious beliefs against vaccination!

My own view is that vaccination is a social good, and there should be no exemptions save medical ones (i.e., people who are ill, immunocompromised, and so on). Vaccinations protect not only the recipient from disease, but also others in society. Even those who are vaccinated could contract a disease from someone unvaccinated for that disease, as vaccinations don’t always “take”. Further, vaccinations are given to babies and children, who lack the capacity to make that decision for themselves. Religious exemptions, in which children go unvaccinated because of their parent’s faith, should not be granted because in that case the good of society, and the right of others not to be injured by your faith-based decisions, trump religious “freedom.”

This is not just a philosophical argument. As the Religon News Service (RNS) reports, there have been epidemics among unvaccinated children—most recently when 25 children were infected with measles because their Texas megachurch frowns on vaccination. And some of those who were infected had been vaccinated, showing that the vaccine doesn’t always protect you—though of course most of the time it does. That provides even more reason to vaccinate everyone, for that reduces the chance of an unvaccinated person encountering one whose vaccination was ineffective.

A quote from the RNS article:

“This is a classic example of how measles is being reintroduced,” said William Schaffner, an infectious disease expert and professor at the Vanderbilt University School of Medicine in Nashville. The U.S. has had more than twice as many confirmed measles cases this year than all of last year, when there were just 55, according to the CDC. Flare-ups brought on by foreign travel have caused that number to spike as high as 220 measles cases in 2011.

There have been other cases as well, involving other diseases:

New York City also has battled a measles epidemic this year, with at least 58 cases, mostly in close-knit Orthodox Jewish communities. City officials say the outbreak was started by someone who traveled to the United Kingdom which, along with Europe, has suffered large measles outbreaks in recent years. One of the New York children with measles developed pneumonia. Two pregnant women were hospitalized and one suffered a miscarriage, city health officials say. Other vaccine-preventable diseases also have broken out in recent years, including whooping cough and mumps. Some whooping cough outbreaks have clustered around private schools with lax vaccination requirements, according to CDC studies.

I see no argument in favor of religious exemption for vaccination when the public safety is at risk.

So how do we ensure mandatory vaccination for all? In the U.S., you usually can’t attend public school without a record of vaccination. This is also true for universities, like the University of Chicago, which still grants religious exemptions from its requirement that entering students show proof of vaccination. But that doesn’t work if you go to a private religious school or are home-schooled:

All of the school-age children infected in the Eagle Mountain outbreak were home-schooled, health officials say. Texas requires children be vaccinated before attending school.

One solution is that birth certificates cannot be made official without vaccination, but that has its own problems, since not all vaccinations are given close to the time of birth. What is clear, however, is that the vaccine-autism connection is now conclusively disproven. And anybody who raises that canard is simply wrong:

In an Aug. 15 statement, Eagle Mountain’s [the Texas megachurch mentioned above] pastor, Terri Pearsons, said she still has some reservations about vaccines. “The concerns we have had are primarily with very young children who have family history of autism and with bundling too many immunizations at one time,” she said.

Sadly, only one of the four commenters in the New York Times agrees with me: Kristen Feemster, “a pediatric infectious diseases physician and health services researcher at the Children’s Hospital of Philadelphia and University of Pennsylvania School of Medicine.” She should know, and she pulls no punches in her piece, “Eliminate vaccine exemptions.”

Personal and religious belief exemptions should be curtailed because some people, whether because of age or compromised immune systems, cannot receive vaccines. They depend on those around them to be protected. Vaccines aren’t the only situation in which we are asked to care about our neighbors. Following traffic laws, drug tests at work, paying taxes — these may go against our beliefs and make us bristle, but we ascribe to them because without this shared responsibility, civil society doesn’t work. Public health is no different.

Indeed. Suppose there was a religion whose tenets were that members didn’t have to obey driving laws. (Yes, I know that’s silly, but some religions prohibit bicycle helmets!). Would we allow that? Of course not, because they’d endanger others. Why is it different with vaccination, especially when the children who don’t get vaccinated aren’t capable of making informed choices? They go unvaccinated as martyrs to their parents’ faith.

A different opinion is expressed by Jennifer Margulis, described as “a fellow at the Schuster Institute at Brandeis University [and] the author of “The Business of Baby.” In her piece, “Parents deserve to have a choice,” she holds “freedom of choice” above public safety:

There is tremendous evidence showing vaccinations prevent childhood diseases. Should public health officials do everything they can to encourage, inform and facilitate childhood vaccinations? Yes. Do they have the right to force parents to vaccinate their children? Absolutely not.

She argues that instead of following the U.S. Center for Disease Control’s schedule for vaccinations, parents should voluntarily adhere to the procedure used in Norway:

An American parent could reasonably decide not to follow the C.D.C.’s current vaccination schedule by choosing to vaccinate on the schedule they use in Norway, which has one of the lowest infant mortality rates in the world. In Norway no childhood vaccinations are routinely given in the first three months of life whereas a 2-month-old American infant has been vaccinated against at least four diseases. At the same time, 99 percent of Norwegian infants are breastfed when they leave the hospital and generous family leave policies facilitate successful (and exclusive) breastfeeding. For an American mom who is exclusively breastfeeding and not putting her child in daycare, following the Norwegian schedule would be a philosophical, evidence-based, demonstrably better choice.

Well, maybe. There is a case to be made that American children may be vaccinated unnecessarily early, but Margulis’s argument is one for delayed vaccination, not no vaccinaton. Still, she wants vaccination to remain elective:

It is a news media-driven misperception that parents who claim philosophical or religious exemptions are uneducated or misinformed. Most parents who individualize the vaccine schedule are actively educating themselves, continually assessing their family’s specific health needs, and doing everything they can to keep their children safe and healthy. Unlike in the United Arab Emirates [where breastfeeding is mandatory for two years after birth], in America we believe parents are capable of making their own decisions about their children’s health. We believe in freedom of choice. This freedom of choice extends to when — and even whether— parents vaccinate their kids.

Who cares what reasons parents have for refusing to vaccinate their children? In fact, Margulis is wrong here. There are plenty of anti-vaxers who are misinformed—who think that vaccines are connected to autism. That is not an “evidence-based” decision. Others have religious beliefs against vaccination, which is also not “evidence-based,” since there’s no evidence for a God who abhors vaccinations. Clearly, many parents are not capable of making good decisions about their children’s health. I’ve written at length on this site about how religious exemptions for child healthcare—and all U.S. states allow some leeway here—have resulted in the horrible deaths of children in religions that refuse medical care (Christian Science, the Jehovah’s Witnesses, some Protestant sects, and so on; see here and here for two of my posts).

There can be no “freedom of choice” when a.) children are involved who aren’t capable of that choice, and b.) the public safety is endangered by adherence to unevidenced religious dogma or the false promulgation of a connection between vaccines and autism. In such cases the rights of society at large trump religion’s “freedom of choice,” just as they would for any religions whose dictates endanger unbelievers or those of other faiths.

The most shameful opinion is that given by former Surgeon General Jocelyn Elders, once the nation’s chief medical officer. In “Religious beliefs are the only valid reason,” she writes:

When you choose not to have your child immunized you’re cheating other kids. Their vaccinations protect your child. Not getting a child immunized is child abuse, even if you’re not using a strap. The only exemption from immunization should be for religious reasons. If you feel that strongly that immunization is not a good idea, then don’t send you kids to school. Don’t make other children, or your child, suffer.

At least she implies that kids who aren’t immunized shouldn’t go to public school, but of course can still go to religious schools where unvaccinated kids can spread disease. Further, Further, Elders doesn’t explain why religious exemptions are more important than what she calls “child abuse”. Is it okay to abuse your children if it’s done for religious reasons? (That, in fact, is what virtually every state in the U.S. allows. As described in my pieces above, the exemptions given to parents who withhold medical care from children are horrifying, and all of us are responsible for the laws that allow that.)

Finally, two people from England weigh in: David Elliman, “a community pediatrician at Whittington Health in London and the immunization expert for the Royal College of Pediatrics and Children’s Health,” and Helen Bedford, a “senior lecturer in children’s health at University College London Institute of Child Health.” Their argument is basically that compulsory vaccination wouldn’t work, and that Brits largely get vaccinated voluntarily:

Publicity about the dangers of not being vaccinated, and clinics open at times that suited families, were the key. Would things have been different if any form of compulsion had been introduced? It is very unlikely. Even where immunization is generally mandatory, in a free democracy, there has almost always been the provision for parents with conscientious objections to withhold their children from the immunization program. When smallpox vaccination was made compulsory in the 19th century in the United Kingdom, it was the poor who suffered. If they persisted in refusing immunization, they were fined or even sent to jail, for inability to pay.

But the question is, of course whether parents should be allowed to withhold vaccinations because of “conscientious objections“. If they’re too poor to pay, the government can help. Vaccinations are cheap.

It’s time, in fact, for us to reexamine those exemptions. In my view they are absolutely unconscionable: a sop to religion when that tenet of religion endangers children—both inside and outside the faith. If you have any doubts, simply read “When Prayer Fails,” by Shawn Francis Peters, which recounts the horrible deaths experienced by sick children and others from whom medical care is withheld on religious grounds. And read the two posts I linked to above. There is simply no religious right, as Elders notes, to abuse your children.

In the end, Elliman and Bedford turn out to be the medical equivalent of religious accommodationists; they are “vaccine accommodationists”:

In an era when people are less accepting of authority and do not expect to do something because the government says so, trying to enforce immunization may actually make matters worse and create martyrs. Those who have genuine religious objections are unlikely to allow their children to be immunized, whatever the penalty. Parents who are hesitating about their vaccine decision because of concerns over vaccine safety may change their minds if given time and an opportunity to discuss their concerns with a well-informed health professional. . . . Indeed one might speculate whether some of the vaccine avoidance in the United States is because it is a requirement rather than because of a genuine objection to the vaccines. If parents are coerced into vaccinating their child, it may not only damage their relationship with their health providers, but be counterproductive. Although very vocal, the truly antivaccine parents are in a very small minority. Now would not seem the time to be more coercive.

This reminds me of religious accommodationists who tell scientists to keep quiet about atheism, for that would make the religious more resistant to accepting evolution. There’s no evidence for that, and there’s none for the contention that compulsory vaccination will make people more resistant.

But, even granting Elliman’s and Bedford’s thesis, when is the time to be more coercive? This argument simply seems silly since they provide no evidence that pressure to vaccinate will be counterproductive.

It is time to get rid of every religiously-based exemption from medical care for children. We cannot allow our children to sicken and die on the basis of superstitions. If an adult Jehovah’s Witness wants to die from refusing blood transfusions—and that happens quite a bit—that’s fine: an adult can make an informed decision, silly as it is. But children indoctrinated in faith aren’t in the same boat. And yes, child Jehovah’s Witnesses do die from this indoctrination: read this chilling article about how those dead, transfusion-refusing children are held up by coreligionists as martyrs to the faith, “youths who put God first.” It is disgusting to every civilized person.

When is the time to be more “coercive”? Now. For a single dead child is one too many.