The Vaccinator’s Dilemma

Among the blessings of modern living, we routinely count standard vaccinations for adults and children. Scourges such as smallpox have been eradicated, due in part to mandatory vaccinations that ensure immunity in entire populations. When I heard that a significant number of parents, including some Orthodox Jews, reject some routine vaccinations, my initial reaction was to chalk it up to a lack of education and an inability to grasp scientific reasoning and evidence. I thought of Typhoid Mary ­Mallon from the early twentieth century, the immigrant cook who refused to comprehend that a healthy woman like her carried deadly microbes and that, along with her legendary peach ice cream, she was giving typhoid to the families that employed her. A Jewish woman recently told a New York Times journalist that the practice of vaccination contradicted her faith, because God created her child perfect and needed no additional human intervention. Her way of thinking, so alien to traditional Judaism, echoes the New Age gurus who rail against Jewish circumcision as an assault on the immaculately formed infant.

I was thus surprised to learn that anti-vaccination agitation is not today an indication of social-economic deprivation and educational backwardness. It flourishes among people of high status. Some are wealthy; others are celebrities. They have the self-confidence to arrive at their own views as they surf the Internet, discuss and consult with like-minded folk, and look up articles in medical journals. They like to think of themselves as sophisticated consumers of technology and scientific services rather than as submissive subjects of an imperious medical establishment.

The anti-vaccination movement gained traction with an article by Dr. Andrew Wakefield in the influential journal The Lancet. He claimed that the MMR vaccine (measles, mumps, and rubella) was implicated in cases of autism. Wakefield was subsequently called to judgment. His article contained serious errors to the point of outright fraud. He was expelled from the medical profession and The Lancet retracted his article. Nonetheless, the article, and other publications of a similar sort, continue to inform opponents of measles vaccination. The very existence of the material, often framed as an exposé of deception and malfeasance among medical professionals, fuels a generalized skepticism about conventional scientific truth among those already inclined to think modern technology has given rise to all sorts of dangers that the authorities are eager to hide.

As I write, David Rosenhan is back in the news almost fifty years after the experiment that made his name, due to Susannah Cahalan’s new book The Great Pretender. Back then, the psychology professor published a paper about how he and eight confederates, after reciting a scripted menu of symptoms at various mental asylums, were all (except for the one who was labeled depressive) quickly diagnosed with paranoid schizophrenia. Following their script, after being admitted to hospital they behaved normally, testing to see if the psychiatric institutions responded to their condition. On average it took almost three weeks for them to be released. Labeled “in remission,” none of the doctors or staff caught on that they were being hoaxed.

The article reporting on these results made a sensation, and Rosenhan was criticized for undermining public confidence in psychiatry and institutionalization. Cahalan argues that Rosenhan’s critics were correct. His experiment contributed to the discrediting of mental institutions and helped push psychiatry toward uniform diagnoses and away from subjective medical judgment. I wonder if ­Cahalan exaggerates: Rosenhan’s study contributed to the preexisting resentment of large psychiatric institutions. Sooner or later, the average American taxpayer and the average American insurer were bound to gravitate toward well-defined, finite diagnoses and treatments. But Cahalan further argues that Rosenhan is likely to have made the psychiatrists in his study look worse by misrepresenting or even fabricating some of his data. In spite of this evidence, Cahalan reports that some professionals today discourage her from disseminating her findings, lest they further weaken public trust in canonical academic scholarship.

Cahalan has mixed feelings about Rosenhan’s ­suspected dishonesty. She has written at length about her own ordeal of psychiatric misdiagnosis, putting her on the side of those such as Rosenhan who helped save countless individuals from being consigned to a system that was often cruel, senseless, and arbitrary. Knowing what we now know and what was even then popularly feared about the “nightmare factories” (to cite the title of Troy Rondinone’s 2019 academic book on the subject), should we not be grateful that potential patients and their families think twice before abdicating their lives to the say-so of medical authorities?

Vaccination is different. Its benefits seem demonstrable beyond reasonable doubt and the alleged side effects are unverified, while the benefits of the mid-twentieth-century mental hospital and its more “heroic” interventions such as lobotomies were not evident, and the destruction they wreaked was visible to the naked eye. But the main reason to support mandatory vaccination is that not requiring it poses a potential threat to the population as a whole. When the vast majority of children are vaccinated against measles, for example, the disease will not spread, and the small, unvaccinated minority is protected by “herd immunity.” They are “free riders” on the system of mandatory vaccination. Once the vaccination rate falls below the high level needed to sustain herd immunity, unvaccinated individuals are exposed to a potent disease that may lead to permanent damage and death. That is why vaccination, especially of schoolchildren, is commonly required by law.

One need not be a bioethics expert to know that Jewish law and thought extols human initiative against evil, particularly in the realm of medicine. R. Yisrael Lifschitz, ­rabbi of Danzig in the early nineteenth century, wrote a classic commentary to the Mishna. He celebrated Edward Jenner as one of the “saints of the nations” for his role in developing the smallpox vaccination. The strong affirmation of modern medicine has guided leading contemporary halakhic authorities. One of them, during a Yiddish Q and A, dismissed objections to vaccination, saying that it is supported by the U.S. government and that good-faith government regulations should be followed. His dictum vindicates government-required vaccination. (It does not touch upon the question of skepticism about the authority of scientists, which might be justified, even if one accepts one’s civic duty to have one’s children vaccinated.)

Let me give the last word to R. Asher Weiss, religious adviser to a prominent Jerusalem hospital. His international stature owes as much to his reputation for levelheadedness as to his erudition. R. Weiss excoriates Wakefield as a corrupt charlatan and regrets his wrongful influence over parents anxious about the well-being of their children. He rules that parents ought to vaccinate their children for their own benefit and also as a social responsibility—for it is immoral to have one’s children shirk inconvenience and minimal risk by taking advantage of the herd immunity conferred by the compliance of other parents.

However, R. Weiss is still troubled by a scenario that is not implausible. Two children in the same family react badly to a vaccination. What should the parents do about the third child? From a strictly scientific perspective, he posits, the two bad outcomes are statistically insignificant. Shall the parents therefore dismiss the suffering of both children as mere coincidence? One would not be wrong to entertain the possibility that there are genetic factors that fall below the threshold of current medical investigation. In light of such a possibility, must the parents jeopardize their third child (as they see it) for the sake of a general principle?

We are now far from the story of Typhoid Mary. As a rabbinic authority, R. Weiss is not sure he would implacably require vaccination for the third child of a couple that has misgivings rooted in their family’s experience. What about us? What, for example, would you, as a doctor, tell these parents? And how far should government officials go in their efforts to lay down the law to the rest of us? We all, I suppose, unhesitatingly believe in science, or at least trust and rely on the consensus of the professionals. But in particular situations, it’s not always clear what we should do, and what we should demand that others do. Along with the benefits of modern science come dilemmas. Science can ameliorate suffering. Its experimental method can provide sound guidance. But science cannot deliver us from the necessity of making hard judgments in difficult cases.

Shalom Carmy teaches Jewish studies and philosophy at Yeshiva University and is editor emeritus of Tradition.