halacha's perspective on vaccination

The questions you have posed touch on several fundamental halachic principles. Rather than getting involved presently with an explication in detail, I hope the following will suffice. Should you have need for a more detailed response please do not hesitate to let me know. Living in the twenty-first century, we have forgotten what the lives of our ancestors were like—filled with sadness for the children afflicted with paralysis from polio and with mourning for children dying of smallpox and measles. For example, in the latter part of the eighteenth century, smallpox decimated Europe. The eradication of smallpox has been one of the greatest achievements of medical science. Smallpox is estimated to have killed more people than any other disease in history, approximately 300 million people in the 20th century alone. Because of the World Health Organization there has not been a singe naturally occurring case of smallpox since 1977 and there has been no need to immunize against the disease in the United States since the early 1970s. Edward Jenner created the very first modern vaccine in 1796 to combat smallpox when he inoculated the first person with cowpox, a related, but much more benign disease, creating immunity to smallpox. Since that time, we have developed many vaccines against many deadly infectious diseases, particularly deadly childhood diseases. The issue of assuming risk is a halachic topic beyond today's quick note, but the assumption of some risk in the pursuit of medical treatment is an accepted fact. All treatments from tylenol to chemotherapy have risks and are not free of side-effects. yet the obligation to seek a cure still exists. Each treatment requires its own risk-benefit analysis. More than two hundred years after Jenner's discovery, the effectiveness of vaccination is unquestionable. While vaccination has led to the virtual eradication of a host of deadly diseases such as polio, whooping cough, diphtheria, and measles, vaccination still remains controversial for some. This is primarily because vaccinations are not without side effects. Rabbi Yisroel Lipshutz, the Rabbi of Danzig, Germany in the 19th century wrote in his commentary Tifferes Yisrael (Avos 3:14) that the smallpox vaccine was permitted despite the risk of death and that Jenner is to be considered a "righteous gentile" for the development of the vaccine. One of the concerns raised, espcially by parents is that anecdotal accounts of vaccinations leading to conditions such as autism exist. But these are not well-documented, scientifically proven side effects. To date, these claims have not been substantiated by rigorous scientific study. In 2004, the Institute of Medicine performed a thorough study on the hypothesis that vaccines, and, in particular, the mercury they contained, were causally related to autism. Its published findings concluded that the body of epidemiological evidence rejects a causal relationship between mercurial-containing vaccines and autism. Just last week, the federal "vaccine court" (shorthand for the Office of Special Masters of the U.S. Court of Federal Claims) rejected claims that either the measles/mumps/rubella (MMR) vaccine or thimerosal in vaccines caused children's autism. An interesting question to be asked is whether once the risk of infection from a communicable disease becomes very small and the majority of people are immunized, must a person accept the risk – even the small risk – of immunization? As the Archives of Pediatrics and Adolescent Medicine (April 2001) explains: Herd immunity, the concept of decreased infection in susceptible individuals as a result of vaccination among household or community contacts, is generally thought to have a positive effect on the public health. Because of herd immunity, the incidence of several vaccine-preventable illnesses has dropped precipitously even though significantly fewer than 100% of the eligible population has been immunized. Statistically, this argument makes sense. Practically, of course, there is a problem for if everyone so argued, no one would be immunized and the threat of deadly disease would rise. Well known is the fact that Rambam derives the obligation to heal from the commandment of hashovat aveida – returning a lost object. Based on a comment of the Sifrei he reasons that if one must return someone's object, surely one must return someone's health. This includes preventing one from losing their health in the first place. Halacha requires us to guard our health and we must therefore seek medical care and avoid unnecessary risk. Indeed the Shulchan Aruch (Y.D. 116ז) says that there is an obligation of actively preventing illness and danger. The chicken pox (varicella) vaccine raises an interesting issue. Chicken pox is usually a benign childhood illness and is certainly rarely fatal. However, while adults are less susceptible to varicella infection, they are more likely to die of chicken pox. A child who develops chicken pox is protected from reinfection (although shingles is a common adult sequella). If we immunize most children, but not all, then the incidence of the disease will drop and those people not immunized will be less likely to develop the disease as a child and more likely to develop it as adults when it is dangerous. In essence, for a small portion of the population we would be shifting the risk of chicken pox from childhood to adulthood and increasing the mortality from chicken pox. If the vaccine afforded protection for life, there would be a very strong argument in favor of universal vaccination. Both children and adults would benefit – children would not develop chicken pox as children or shingles as adults and no adults would be vulnerable to chicken pox as adults. But what if the vaccine only protects a person for twenty-five years? Should we not worry that we will push off chicken pox in the entire population from childhood when it is benign to adulthood when it can be deadly? While boosters can be given, realistically, many people will never receive the booster and these people would have been better off developing the disease as a child. Vaccines come in two main types: live and killed viruses. For example, the original Salk injected vaccine for polio, developed in the 1950's, is a killed virus, with no known risk of causing polio. The Sabin oral vaccine is a live attenuated virus, that has a one in two to four million chance of causing polio. The argument for use of the Sabin is that the Sabin vaccine causes an intestinal infection with the weakened virus, induces immunity in the individual who is immunized. Since the immunized person is infected with the weakened virus, they can spread it to the people around them. This allows immunization even of people who do not receive the oral vaccine. The down side arises from this very advantage – since the Sabin vaccine is a live virus it has a small risk of causing polio in those who are immunized directly or indirectly. While the Salk vaccine can protect the individual who has been immunized, it cannot stop epidemics. On the other hand, the Sabin vaccine can prevent epidemics by vaccinating even those not receiving the immunization, but it has a very small, but serious, danger. When polio was a major health threat, the United States utilized the Sabin vaccine. Now that the risk of polio has declined to near the risk of the oral vaccine, the United States has reverted to the Salk vaccine. Rabbi David I. Kaye Director, Department of Pastoral Services Chair, Medical Ethics Parker Jewish Institute for Health Care and Rehabilitation