Immunizations, Newborn Screening and Religious Exemptions: Where Lies the Justificatory Burden?
Michael Deem, Ph.D., Assistant Professor of Philosophy/Pediatric Ethics and Genomics Fellow, Indiana State University/Children's Mercy Hospitals and Clinics
Parents generally have the right to make medical decisions for their children. There are, however, widely recognized limits to that authority. In cases where parents’ medical decisions imperil a child’s life or health, the duty to respect parental discretion is generally overridden by the duty to promote and protect the health interests of the child. Difficult cases arise, however, when there is no immediately threat to a child’s life or health, but in which the failure to provide a recommended medical treatment may increase the risk of severe morbidity or death, or place at significant risk the health of other children. In such cases, should the parental right to make medical decisions prevail over the authority of the state and the medical profession to determine what is in the child’s best interest?
Most state laws allow religious exemptions from newborn screening programs and from mandated childhood immunization. This paper considers the question of whether parental refusal of these services can be justified on strictly religious grounds. Some ethicists have argued that parental refusal of newborn screening for serious or lethal conditions for which there are proven interventions is not ethically justifiable even for religious reasons (e.g., Faden et al. 1982; Newson 2006). Others have argued on ethical and public health grounds that personal belief exemptions for certain vaccines should be eliminated (e.g., Lantos et al. 2012). While I agree that in some, perhaps many, cases parental refusals of newborn screening or childhood immunization on religious grounds are not ethically justified, I argue that the ethical considerations do not favor altogether eliminating religious exemptions.
What kind of justification is needed for parental refusal of mandated newborn screening and childhood immunization? Here I propose what I call an accessibility constraint on parental refusal of these medical services. An accessibility constraint requires parents who refuse these services to provide justification for their decision by way of reasons that are accessible to any rational, informed person. To be accessible in this way, these reasons must be shareable with any such person—that is, capable of being held apart from any particular religious view—and appraisable by any such person—that is, capable being assessed independently of any particular religious view.
In seeking accessible reasons for refusal, health care professionals ensure they are meeting some of their fiduciary obligations to the child. By the same token, the imposition of an accessibility constraint is more respectful of parental authority and religious identity than rescindment of non-medical exemptions to critical newborn screening and childhood immunization. While the constraint places a justificatory burden on parents who wish to decline these services, it does not foreclose the possibility of justified refusal. Thus, an accessibility constraint functions as an important safeguard against an overly deferential stance toward parental preferences whenever the welfare of the child or public health might be placed at significant risk by parents’ decisions about care.
Parents generally have the right to make medical decisions for their children. There are, however, widely recognized limits to that authority. In cases where parents’ medical decisions imperil a child’s life or health, the duty to respect parental discretion is generally overridden by the duty to promote and protect the health interests of the child. Difficult cases arise, however, when there is no immediately threat to a child’s life or health, but in which the failure to provide a recommended medical treatment may increase the risk of severe morbidity or death, or place at significant risk the health of other children. In such cases, should the parental right to make medical decisions prevail over the authority of the state and the medical profession to determine what is in the child’s best interest?
Most state laws allow religious exemptions from newborn screening programs and from mandated childhood immunization. This paper considers the question of whether parental refusal of these services can be justified on strictly religious grounds. Some ethicists have argued that parental refusal of newborn screening for serious or lethal conditions for which there are proven interventions is not ethically justifiable even for religious reasons (e.g., Faden et al. 1982; Newson 2006). Others have argued on ethical and public health grounds that personal belief exemptions for certain vaccines should be eliminated (e.g., Lantos et al. 2012). While I agree that in some, perhaps many, cases parental refusals of newborn screening or childhood immunization on religious grounds are not ethically justified, I argue that the ethical considerations do not favor altogether eliminating religious exemptions.
What kind of justification is needed for parental refusal of mandated newborn screening and childhood immunization? Here I propose what I call an accessibility constraint on parental refusal of these medical services. An accessibility constraint requires parents who refuse these services to provide justification for their decision by way of reasons that are accessible to any rational, informed person. To be accessible in this way, these reasons must be shareable with any such person—that is, capable of being held apart from any particular religious view—and appraisable by any such person—that is, capable being assessed independently of any particular religious view.
In seeking accessible reasons for refusal, health care professionals ensure they are meeting some of their fiduciary obligations to the child. By the same token, the imposition of an accessibility constraint is more respectful of parental authority and religious identity than rescindment of non-medical exemptions to critical newborn screening and childhood immunization. While the constraint places a justificatory burden on parents who wish to decline these services, it does not foreclose the possibility of justified refusal. Thus, an accessibility constraint functions as an important safeguard against an overly deferential stance toward parental preferences whenever the welfare of the child or public health might be placed at significant risk by parents’ decisions about care.