JAMA Forum: Public Health vs Personal Liberty: Reflections on the California Vaccination Law

Eli Adashi, MD, MS (Image: Brown University)

Eli Adashi, MD, MS (Image: Brown University)

On June 30, when California Governor Jerry Brown signed into law new legislation that requires most children in the state to be vaccinated, public health was pitted once again against personal liberty. “The science is clear that vaccines dramatically protect children against a number of infectious and dangerous diseases,” Gov Brown said in a prepared statement. “While it’s true that no medical intervention is without risk, the evidence shows that immunization powerfully benefits and protects the community.”

The new law does away with vaccination exemptions based upon religious or personal beliefs. Exemptions from immunization on medical grounds will remain in effect, but with few exceptions, children enrolled in classroom-based education will be subject to mandatory immunization schedules.

All told, as many as 80 000 pupils who have claimed vaccination exemptions based on personal or religious grounds stand to be affected. Unvaccinated pupils will be precluded from enrolling in private or public elementary or secondary schools, child care centers, or development centers. However, pupils receiving home-based private schooling, as well as students enrolled in an independent study program “who do not receive classroom-based instruction,” would be exempted.

The bill, which was sponsored by 2 Democratic state senators, Richard Pan (D, Sacramento) and Ben Allen (D, Santa Monica), was introduced on February 19, 2015, in the wake of a measles outbreak that included 178 cases from 24 states and the District of Columbia. Most of the cases (117 individuals, or 66%) were linked to an outbreak that began in late December at 2 Disneyland theme parks in Anaheim, California. Overall, the vast majority of the measles cases were California residents, many of whom declined vaccination on philosophical and religious grounds.

The new law is scheduled to go into effect on July 1, 2016. But if opponents succeed in gathering the necessary 365 880 valid signatures to place a referendum on the law on the November 1, 2016, ballot, the law’s implementation would be put on hold, pending the outcome of the vote. Even if the law survives the referendum vote, the possibility of a delay due to a legal challenge cannot be ruled out.

States Vaccination Mandates

Laws regulating vaccination are the domain of the states. However, the scope of state vaccination mandates varies considerably. All 50 states exempt children from vaccination on medical grounds. Most states (48) allow exemptions for children on religious grounds, and 17 states exempt children from vaccination on miscellaneous ill-defined philosophical grounds.

In enacting the law, California joins Mississippi and West Virginia as the only states to limit vaccination waivers to medical reasons. However, other states may follow suit, recognizing that declining vaccination rates pose risks to the public, as illustrated by 668 measles cases from 27 states in 2014, the largest number since 1994. More than half of the 2014 cases were linked to an outbreak occurring primarily in Amish communities in Ohio whose children had been exempted from vaccination on religious grounds. Absent extensive rewriting of current state vaccination laws, there is every reason to believe that more of the same is all but inevitable.

An Old Debate

The debate over vaccination laws dates back to the very birth of the nation. In 1776, the Massachusetts General Court (the Commonwealth of Massachusetts’ lawmaking body) abolished a ban on smallpox inoculation. Only vaccinated individuals or previously infected survivors were to be allowed to enter the city.

Echoes of this historic debate over the conflict of the public good with individual liberties clearly played out in the California legislature over the new immunization legislation. “Do we wait until we have a full-fledged crisis to protect the most vulnerable?” asked state assemblywoman Lorena Gonzalez, arguing for the primacy of public health. Similar sentiments were articulated by assemblywoman Catharine Baker (R, San Ramon). “I’m a fierce supporter of parent choice in this decision,” she said. “But I also believe that with choice comes personal responsibility.”

To others, however, the law represented government overreach, an erosion of religious freedom, and a threat to carefully guarded personal liberties. The law constituted “a direct attack on our liberty and a violation of personal rights,” said state senator Joel Anderson (R, Alpine). “We do not have the right, nor should we have the power, to take away a parent’s right to choose,” said assemblyman Devon Mathis (R, Visalia).

The debate over vaccination laws is in many ways quintessential American, in that its vigorous libertarian streak has few, if any, rivals among developed nations. In addition to seeing itself as the “land of the free” that enshrined “liberty” in its Declaration of Independence, the United States is also home to a “rugged individualism,” where religious freedom and other civil liberties are encoded in the Constitution.

Against this backdrop, it is hardly surprising that many would view the California vaccination law as heavy-handed and intrusive. For now, US pluralism has carried the day, and the same principle will be operational if a recall referendum materializes. After all, the adjudication of diversity by majority rule is what this political philosophy is all about.

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About the author: Eli Y. Adashi, MD, MS (eli_adashi@brown.edu) is a professor of medical science and the former dean of medicine and biological sciences at the Warren Alpert Medical School of Brown University in Providence, Rhode Island. A member of the Institute of Medicine, the Association of American Physicians, and the American Association for the Advancement of Science, Adashi has focused his writing on domestic and global health policy at the nexus of medicine, law, ethics, and social justice. A former Franklin fellow, Adashi served as a senior advisor on global women’s health to the Secretary of State office of Global Women’s Issues during the first term of the Obama Administration.

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.



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