Vaccines & Jewish Law Contemporary Halakhic Quandaries Young of West Hartford Tuvia Brander [email protected]

1. Infectious Diseases Society of America, Always-deadly measles complication more common than believed 10/28/16 Subacute sclerosing panencephalitis (SSPE) is a neurological disorder that is 100 percent fatal. Infants younger than 12 months, who are too young to receive measles, mumps and rubella (MMR) vaccine, can infected with measles and later develop SSPE, which may lay dormant for years. While it was once thought the risk of post-measles SSPE was one in 100,000, recent research identified a rate as low as 1 in 1,700 in Germany among children infected with measles before they were 5 years old, and the new study found it is about one in 600 for those who get measles as infants before being vaccinated. There is no cure for SSPE and the only way to prevent it is to vaccinate everyone against measles.

2. Non-Medical State Exemptions from School Immunizations, 2017 (from National Conference of State Legislatures; www.ncsl.org)

3. , Shabbat 82a אמר ליה רב הונא לרבה בריה מאי טעמא לא שכיחת קמיה דרב חסדא דמחדדן שמעתיה אמר ליה אמאי איזיל לגביה דכי אזילנא לגביה מותיב לי במילי דעלמא אמר לי מאן דעייל לבית הכסא לא ליתיב בהדיא ולא ליטרח טפי... אמר ליה הוא עסיק בחיי דברייתא ואת אמרת במילי דעלמא כל שכן זיל לגביה Huna said to his son Rabbah: Why are you not [learning] before Rav Chisda, whose lessons are sharp? Rabbah replied: Why should I go to him? He questions me about mundane matters! He tells me, "One who goes to the washroom should not sit immediately or press too hard…" replied: He is involved in human life, and you say "mundane matters"? You certainly should go to him! Contemporary Halakhic Quandaries: 1 Vaccines & Jewish Law 1

4. Maimonides, Mishneh , Hilchot Deiot 4:1 הואיל והיות הגוף בריא ושלם מדרכי ד' הוא, שהרי אי אפשר שיבין או ידע דבר מידיעת הבורא והוא חולה, לפיכך צריך להרחיק אדם עצמו מדברים המאבדין את הגוף, ולהנהיג עצמו בדברים המברין והמחלימים... Having a healthy, whole body is from the paths of God, as one can neither understand nor know anything about God when ill. Therefore, one must distance himself from anything which damages the body, and one must accustom himself to behaviors which increase health and strength…

5. Talmud, Bava Kama 15b רבי נתן אומר מניין שלא יגדל אדם כלב רע בתוך ביתו ואל יעמיד סולם רעוע בתוך ביתו ת"ל לא תשים דמים בביתך Rabbi Natan said: How do we know that one may not raise a bad dog in his home, and one may not set up a weakened ladder in his home? 22:8 says, “You shall not place blood in your home.”

6. Maimonides, Sefer haMitzvot, Lo Taaseh 298 שהזהירנו מהניח המוקשים והמכשולות בארצותינו ובבתינו כדי שלא ימותו בהם בני אדם . He commanded us not to leave obstacles and stumbling blocks in our lands and homes, lest people die by them.

7. Maimonides, Mishneh Torah, Hilchot Rotzeiach uShemirat haNefesh 11:4 וכן כל מכשול שיש בו סכנת נפשות מצות עשה להסירו ולהשמר ממנו ולהזהר בדבר יפה יפה שנ' (דברים ד' ט') השמר לך ושמור נפשך ,ואם לא הסיר, והניח המכשולות המביאין לידי סכנה, ביטל מצות עשה ועבר על "לא תשים דמים ." So, too, there is a commandment to remove any stumbling block which endangers lives, and to guard from it, and to be very careful with this, as Devarim 4:9 says, “Guard yourself, and guard your life.” And if one does not remove it, and one leaves dangerous stumbling blocks, he fails to fulfill a commandment, and he violates “Do not place blood.”

8. Rabbi (1973), Igrot Moshe Even haEzer 4:10 כיון שעתה נעשה זה באופן קל לבדוק יש לדון שאם אינו בודק את עצמו הוא כסגירת העינים לראות מה שאפשר לראות, ומכיון שאם ח"ו אירע דבר כזה הוא להורי הילד צער גדול מאד מן הראוי למי שצריך לישא אשה לבדוק את עצמו. Since it is easy to check, one should realize that failure to check one's self would be like closing one's eyes before that which one could see. G-d forbid, such an event would cause the child's parents extraordinary pain, and so it would be appropriate for a man who wished to wed a woman to test himself.

9. Maimonides, Mishneh Torah, Hilchot Rotzeiach uShemirat haNefesh 11:5 הרבה דברים אסרו חכמים מפני שיש בהם סכנת נפשות וכל העובר עליהן ואמר הריני מסכן בעצמי ומה לאחרים עלי בכך או איני מקפיד על כך מכין אותו מכת מרדות . The sages prohibited many activities because they endanger lives. Regarding anyone who transgresses, and who says, “I will endanger myself, and what business is it of others?” or “I don’t care”, we issue lashes of rebellion for him.

10. Talmud, Bava Metzia 112a "ואליו הוא נשא את נפשו" - מפני מה עלה זה בכבש ונתלה באילן ומסר את עצמו למיתה - לא על שכרו ? "For this he puts his life on the line (Devarim 24:15)" – Why did this person climb the ramp, become suspended from the tree, and give his life over to ? Was it not for his wages?

11. Talmud, Yevamot 72a א"ר פפא הלכך יומא דעיבא ויומא דשותא לא מהלינן ביה ולא מסוכרינן ביה והאידנא דדשו בה רבים שומר פתאים ד' said: Therefore, we neither circumcise nor let blood on a cloudy day, or a day when the south wind blows. But now, when the masses trample this, we invoke Tehillim 116:6, “G-d guards the fools.”

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12. Rabbi Chaim Ozer (Early 20th century ), Achiezer 1:23 ועכצ"ל דזהו באמת חשש רחוק ומיעוט שאינו מצוי דלא חיישי רבנן להאי ועל זה יש לסמוך משום שומר פתאים . One must conclude that [conception] is very unlikely to be a concern, a rare minority of cases, and the sages weren’t concerned for this. For this, one may rely upon “Guards the fools.”

13. Rabbi Moshe Feinstein (1981), Igrot Moshe Choshen Mishpat 2:76 על כל הדברים האלו שפרט אותם לא שייך לאוסרן ממש מאחר דהרוב מהן עניני הנאה הן ולרובא דרובא דאינשי לא מזיק להו כלום ואיכא הרבה מהן שא"א להזהר בהו להרבה אינשי שטרידי בפרנסתן... שלכן לא שייך לאסור אלא רק לעורר להעלמא במה שידעו איזה דבר הוא טוב ואיזה דבר הוא רע וליעץ להם... Regarding all of these practices which [Rambam] specified, it is not relevant to actually prohibit them, since most of them are pleasures which do not harm the great majority of people, and many of these practices are unavoidable for people who are busy with their work… So it is not relevant to prohibit them, but only to alert people so that they will know what is good and what is bad, and to counsel them…

14. Rabbi Yaakov Ettlinger (19th century Germany), Binyan Tzion 137 אף על גב דכלל בידינו דאין לך דבר עומד בפני פקוח נפש ואין הולכין בפ"נ אחר הרוב זה דוקא ביש ודאי סכנת נפש לפנינו כגון בנפל עליו הגל דאז חוששין אפילו למיעוטא דמיעוטא אבל בשעתה אין כאן פקוח נפש רק שיש לחוש לסכנה הבאה בזה אזלינן בתר רובא כמו לענין איסורא דאל"כ איך מותר לירד לים ולצאת למדבר שהם מהדברים שצריכין להודות על שנצולו Even though we have a principle that nothing stands before guarding a life, and we do not follow the majority in matters of guarding a life, that is only where there is a definite threat to life before us. For example, this is where someone is beneath a ruin, and we are concerned for even a tiny minority [possibility that he yet lives]. But where there is no need to guard a life right now, but only to be concerned for a future danger, we follow the majority as we do regarding prohibitions. Otherwise, how could one enter the sea, or go into the wilderness, activities for which we thank Gd when we are saved!

15. Rabbi Aryeh Lipschitz (19th century Vilna), Shem Aryeh 27 ...לפרוש לים הגדול לשוט, היינו כדי לשוטט בעולם ולראות דברים חדשים... מהראוי להרחיק מזה, רק לצורך מזונות או לסחורה To go to sea in the Mediterranean, meaning to wander the world and see new things… It would be appropriate to avoid this, but only to go for livelihood or trade

16. Talmud, Berachot 33a "אפילו נחש כרוך על עקבו לא יפסיק." אמר רב ששת לא שנו אלא נחש אבל עקרב פוסק The mishnah said, “Even if a snake is wrapped around one’s ankle, he should not stop [the amidah].” Rav said: This is only for a snake; for a scorpion, one should stop.

17. Rabbi , Journal of Halachah and Contemporary Society 69 (Spring 2015) pg. 100 One can see from this that Minchat Shlomo [Rav ] is of the opinion that if most people assume that not being vaccinated is a sakanah, then – although the possibility of danger is quite remote – in specific situations it would be permitted to desecrate the Sabbath in order to be vaccinated, and surely someone must obtain vaccination on a weekday since the public considers not vaccinating to be a sakanah, albeit a remote danger.

18. Rabbi J. David Bleich, Vaccination, Tradition 48:2-3 (2015) pp. 53-54 Nor can the principle of shomer peta’im be invoked to justify assumption of a recognized danger that can be readily averted. That is clearly the import of the statement of R. Moshe Feinstein, Iggerot Mosheh, Even ha-Ezer, IV, no. 10, to the effect that, with the development of blood tests to determine whether prospective marriage partners are both carriers of the gene responsible for Tay-Sachs disease, one may no longer rely upon shomer peta’im in assuming the Contemporary Halakhic Quandaries: 1 Vaccines & Jewish Law 3

risk of that disease. For precisely the same reason, a danger posed by childhood disease for which a vaccine is available may not be assumed on the plea of shomer peta’im. That is certainly the import of the statement attributed to the late R. to the effect that “failure to immunize would amount to negligence.” Perfection of vaccines that immunize against disease results in a situation in which failure to vaccinate is tantamount to willfully exposing oneself to zinim pahim. Once divine providence has made a vaccine safely available, any misfortune resulting from failing to avail oneself of immunization is to be attributed to human negligence rather than to divine decree.

19. Rabbi Yisrael Isserlein (15th century Germany), Terumat haDeshen 211 וצ"ע אי שייך למימר האי טעמא שומר פתאים לתלמיד חכם שהוא יודע ומכיר ונזכר למופלא בדורו This requires examination – can one say “Guards the fools” for a Torah scholar who knows and understands, and is known as a stand-out in his generation?

20. Dr. Daniel Eisenberg, The Ethics of Smallpox Immunization, http://www.aish.com/ci/sam/48943486.html One may suggest that the halachic concept of "God watches over the simple," in cases of risk that are generally accepted by the community might allow me to forgo immunization. This would be a difficult argument to make since most people are not willing to accept the risk of forgoing vaccination.

21. Rabbi Moshe Feinstein, Igrot Moshe Choshen Mishpat 2:73:5 אם הוא מחמת שאינו מאמין לרופאים אלו צריכין למצא רופא שמאמין בו, ואם ליכא רופא כזה ואי אפשר לפניו מצד המחלה לחכות עד שיבין שהוא לטובתו וגם לא לשלחו כשרוצה בבית חולים וברופאים שהם בעיר אחרת מוכרחין הרופאים שבכאן לעשות בעל כורחיה אם כל הרופאים שבבית חולים זה סוברים שזהו רפואתו, וגם יהיה באופן שלא יתבעת מזה שאם יתבעת מזה אפילו שהוא ענין שטות אין לעשות כי הביעתותא אפשר שיזיקהו וגם ימיתהו ויהיה זה כהמיתוהו בידים... If a patient’s refusal is because he does not trust the doctors, then they must find a doctor he trusts. If there is no such doctor, and the disease is such that we cannot wait for him to understand that this is for his own good, and we cannot send him to another hospital and doctors in another town, then the doctors here must treat him against his will, if all of the doctors in this hospital believe that this is the way to cure him. This should be done in such a way that he is not frightened, even if his fright is foolish, for the fright could harm him, even fatally, and that would be like actively killing him…

22. Rabbi Yaakov Emden (18th century Germany), Mor uKetziah Orach Chaim 328 בחולי ומכה שבגלוי שיש לרופא ידיעה ודאית והכרה ברורה בהם, ועוסק בתרופה בדוקה וגמורה, ודאי לעולם כופין לחולה המסרב במקום סכנה With an illness or visible wound, for which has a doctor has certain knowledge and clear understanding, and he prescribes a tested, complete treatment, we certainly compel a recalcitrant patient, if the alternative would be dangerous

23. Rabbi Moshe Feinstein, Igrot Moshe Yoreh Deah 3:36 כשהרוב הוא לחיים מסתבר שחייב כדכתב גם כתר"ה מסברא, אבל בספק השקול מסתבר שאין לחייבו, דאם הוא חס על חיי שעה שלו הודאין ואינו רוצה ליכנס בספק לאבד זה בשביל ספק שירויח עוד זמן ודאי רשאי... It is logical to say that when most patients live, he is obligated [to undergo the treatment], but if the odds are even then it is logical to say we should not obligate the patient. If he is concerned for his definite, short-term life, and he does not want to enter into possibly losing that life for the possibility of gaining more time, he certainly is licensed…

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24. Maimonides, Guide of the Perplexed 3:37 ואמרו בפירוש כל שיש בו משום רפואה אין בו משום דרכי האמורי, רוצים בזה שכל מה שיגזרהו העיון הטבעי הוא מותר וזולתו אסור ...כל מה שנתאמת נסיונו באלו אע"פ שלא יגזרהו ההיקש הוא מותר לעשותו The sages said explicitly that medicinal treatments are not subject to "Emorite ways", meaning that anything mandated by natural studies is permitted, and anything else is prohibited… Anything proven by experience may be practiced, even where logic does not dictate it.

25. Rabbi Moshe Sofer (18th century Pressburg), Chatam Sofer Yoreh Deah 45 והנסיון הוא עד נאמן יותר מכל הסברות הבנוייות על ראיות Experience is a more honest witness than all of the theories founded upon proofs.

26. Rabbi Yaakov Emden (18th century Germany), Mor uKetziah Orach Chaim 328 אף הסתמית ע"י רופא מומחה, כודאית חשיבא Even an unknown treatment is considered certain, if authorized by an expert physician.

27. Rabbi Chaim Yosef David Azulai (18th century Italy), Shiyurei Berachah to Birkei Yosef, Orach Chaim 328:1 והיום שאין שום אדם יכול לרפאות כי אם ברשות חכמיהם, סתם כל עוסק ברפואה נקרא מומחה. מהרי"ל ואלי . Today, when no one can heal without license from their scholars, all who are involved in treating are called "experts".

28. Ramban (13th century Spain), Torat ha'Adam, Sakkanah 6 בפרק החובל (פ"ה ב') תנא דבי ר' ישמעאל ורפא ירפא מכאן שניתנה רשות לרופא לרפאות. פי' שמא יאמר הרופא מה לי בצער הזה שמא אטעה ונמצאתי הורג נפשות בשוגג לפיכך נתנה לו תורה רשות לרפאות . The Talmud records, "They taught in the of Rabbi Yishmael: The Torah says, 'He shall surely heal.' From here we see that permission is given to doctors to heal." This means the following: lest a doctor say, "What do I need with this pain? I might err and kill accidentally," the Torah permitted him to heal.

29. Rabbi Moshe Isserles (16th century Poland), Code of Jewish Law, Yoreh Deah 116:5 וכן יזהר מכל דברים המביאים לידי סכנה, כי סכנתא חמירא מאיסורא... עוד כתבו שיש לברוח מן העיר כשדבר בעיר, ויש לצאת מן העיר בתחלת הדבר, ולא בסופו (תשובת מהרי"ל סי' מ"א .) One should avoid all that introduces risk, for danger is more serious than prohibitions… One should flee a city when there is plague present – and one should flee at the start of the plague, not at its end.

30. DiPoce and Buchbinder, Preventive Medicine, Journal of Halachah and Contemporary Society 42 (2001), pg. 98 Rav Hershel Shachter explains that when one’s risk of developing disease is a miut hamatzui [small, yet recognizable] one would be obligated to undergo the appropriate testing for the disease. Rav Shachter suggests that a miut hamatzui would be in the range of 10%... Thus, if a person’s risk were in the range of 10%, he would be obligated to be vaccinated. [Footnote: He asserted that if the adverse reaction risk for a given vaccine was in the range of 1 in 1,000,000, the concept of batla daito eitzel kol adam would be applied to mitigate an individual’s fear which might have prevented him from being vaccinated.]

31. Rabbi Yosef Shalom Elyashiv (20th century Israel), cited in Rabbi Dr. Akiva Tatz, Dangerous Diseases and Dangerous Therapy in Jewish Medical Ethics, pg. 48

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In fact, Rabbi Elyashiv went so far as to assert that failure to immunize would amount to negligence. Refusing childhood immunizations on the basis of unsubstantiated fears of vaccine side-effects is irresponsible and out of order halachically.

32. Kant, Immanuel [1785]. Grounding for the Metaphysics of Morals. 4:421 Act only according to that maxim whereby you can, at the same time, will that it should become a universal law.

33. Talmud, Kiddushin 29a ת"ר: האב חייב בבנו למולו, ולפדותו, וללמדו תורה, ולהשיאו אשה, וללמדו אומנות. וי"א אף להשיטו במים . Our sages taught: A father’s obligations to his son are: To circumcise him, redeem him, teach him Torah, marry him off, and train him in a trade. And some say to train him to swim.

34. Rabbi Asher Bush, Vaccination in Halakhah and in Practice in the Orthodox Jewish Community, Hakirah 13 (2012) More recently Rav Elyashiv has been quoted in writing as saying that the parents of vaccinated students have the right to insist that all other classmates be vaccinated so as not to subject their children to unnecessary risk of illness.

35. Rabbi J. David Bleich, Vaccination, Tradition 48:2-3 (2015) pp. 53-54 A person is certainly under no obligation to allow others to pose harm to him or to his children. In days gone by, a teacher accepted students for tutelage exercising discretion in choosing his charges in the manner of any other artisan or professional. Alternatively, a group of parents cooperatively engaged a teacher to provide instruction for their children. Such arrangements were entirely at the discretion of the parents and the teachers. Presently for better or for worse, entire schools are established in much the same manner by a single educator or by a group of administrators… Communal institutions must be concerned with the educational welfare of all children in the community. Yet, even such institutions dare not sacrifice the many for the sake of the few. Quite to the contrary, their mandate is to maximize educational opportunities by safeguarding the health and welfare of all prospective students. Policy decisions by community schools regarding admission of unvaccinated children should be made by judiciously weighing the risks and benefits involved. The danger of contagion may vary from time to time and from locale to locale...

36. Rabbi Eliezer Waldenberg (20th century Israel), Tzitz Eliezer 9:17:5:8-9 עוד עולה בדעתי דיש לומר דברופא מכיון שזהו גדרו של עולם ומנהגו שהרופא המכיר במחלות ובנגעי בני אדם מגיש להם להעזרה הדרושה ,ואם לא כן תבוא אנדרלמוסיא גדולה בקרב החולים והבריאים גם יחד, א"כ על כגון דא מכיון שנוהג כמנהגו של עולם ותיקונו אין בסיכונו זה כדי לרפאות החולים בכדי להחשיבו כמכניס א"ע באיסור בסכנה בכדי להציל חבירו ...ועוד זאת נלפענ"ד דבהיות דהרופא עושה כן ליטפל בחולים עבור פרנסתו א"כ מותר לו משום כך ליכנס גם בספק סכנה, ובדומה למה שהתירה תורה לפועל ליכנס למקומות סכנה עבור פרנסתו... It further appears to me that one could say this regarding a doctor: Since it is standard that the doctor, who knows diseases and ailments, provides necessary aid, and without this there would be great devastation for the ill and the healthy. Therefore, he is acting in a standard way, for the normal function of the world, and the risk involved in treating the sick is not considered "introducing oneself into forbidden risk"… It further appears, in my humble opinion, that since the doctor does this to treat the sick for a living, he is permitted to introduce himself into possible danger for this. It is like the way the Torah permitted a worker to enter danger for his livelihood…

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37. Letter by Rabbi Shmuel Meir Katz, Rabbi & Rabbi , 13 Kislev 5770 After considering the nature of the current outbreak, the very high percentage of fully vaccinated individuals among the mumps cases, the serious risks associated with the MMR vaccine, and the halachic gravity of denying a child acceptance to school even for one day, it is our opinion that, unless truly obligated to do so law, no school has the right to deny a child acceptance to school on the grounds that he or she has not received the MMR vaccine. It is and not , הכלה incumbent upon the Menahalim to insure that school nurses act in this regard in accordance with based on secular medical advice alone.

38. DiPoce and Buchbinder, Preventive Medicine, Journal of Halachah and Contemporary Society 42 (2001), pg. 99 Rav Shachter also asserted that where vaccines are mandated by the state, such as in the case of immunizations before entering school, one would be obligated to be immunized based on the concept of Dina d’Malchuta Dina [the law of the land is the law]….

39. Rabbi Asher Bush, Vaccination in Halakhah and in Practice in the Orthodox Jewish Community, Hakirah 13 (2012) Religious Exemptions: In numerous states parents wishing not to vaccinate their children are permitted to sign a document stating that their religious convictions do not allow them to; based on this signature the child will then be permitted to attend school under the law. It is reported that small numbers of parents in Jewish schools have signed such documents. For a parent of a yeshiva student to sign such a statement in the name of is not just inappropriate, it is false. Whether a will rule that childhood immunizations are obligatory in halakhah or are discretionary (but highly advisable), there is no position in halakhah that says there is any prohibition or compelling reason to refrain from such vaccinations. The New York State Department of Health allows exemptions for parents professing “genuine and sincere religious beliefs” that are contrary to immunization. As stated above, there is no validity to any suggestion that vaccinations are contrary to Jewish beliefs or practices. As such, to sign an affidavit in the name of Torah observance is simply false and should have no place in a yeshiva….. On the other hand, some states allow exemptions based on “personal beliefs” (not specifically religious beliefs). While there is nothing dishonest about a yeshiva parent having such a personal belief, it is a misguided one that should be corrected.

40. Talmud, Menachot 64a חולה שאמדוהו לגרוגרת אחת ורצו עשרה בני אדם והביאו עשרה גרוגרות בבת אחת פטורין אפילו בזה אחר זה אפילו קדם והבריא בראשונה If a patient is evaluated to need one fig, and ten men rush and bring him ten figs at once, they are all exempt, and even if they come in sequence, and even if he is healed with the first

Statement on Vaccinations from the OU and Rabbinical Council of America Jun 17, 2015 -- Updated June 17, 2015

Orthodox Jewish parents, like responsible parents across the United States, overwhelmingly vaccinate their children against measles, mumps, rubella, polio and the other childhood diseases for which inoculations are now almost miraculously commonplace. As in many communities, a small minority of parents chooses not to do so. The ongoing measles outbreak demonstrates how this could bear very serious consequences, not only for their own children but others’ too, especially those medically unable to be vaccinated. The Orthodox Union (OU) and the Rabbinical Council of America (RCA) strongly urge all parents to vaccinate their healthy children on the timetable recommended by their pediatrician.

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Parents who choose to not vaccinate often cite a medical study that purported to link autism and the MMR vaccine. The study was discovered to be fraudulent and was withdrawn; its lead author was found to have acted “dishonestly and irresponsibly,” and his license to practice medicine in Britain was revoked.

Judaism places the highest value on preserving human life. It is well known that those facing even a potential life or death situation are instructed to set aside the Sabbath and other key tenets of halachic (Jewish law) observance until the emergency has passed. Prayers for good health and for the complete and perfect healing of the ill are an ages-old aspect of Jewish tradition. But prayers must go hand-in-hand with availing oneself of medical science, including vaccination.

There are halachic obligations to care for one’s own health as well as to take measures to prevent harm and illness to others, and Jewish law defers to the consensus of medical experts in determining and prescribing appropriate medical responses to illness and prevention. Therefore, the consensus of major poskim (halachic decisors) supports the vaccination of children to protect them from disease, to eradicate illness from the larger community through so-called herd immunity, and thus to protect others who may be vulnerable. While the health of children is an important consideration, everyone should consult with his or her religious, medical and legal advisors in determining what actions to take. Nothing in this statement should be construed to add to or detract from rights or obligations created by New York or other state and federal statutes and regulations.

**This source sheet is adapted from source material of Rabbi Mordechai Torczyner of Yeshiva University Torah Mitzion Beit Midrash in Toronto 1. Avraham ben Shlomo Nansich, Aleh Terufah (London, 1785): 545 2. On the history of the rabbinic response to smallpox inoculation, see, for example, Rabbi Pinchas Eliyahu Hurwitz, Sefer HaBrit (, 5750), 247ff.; H. J. Zimmels, Magicians, Theologians, and Doctors (London, 1952), 107-110; D. Margalit, “Smallpox Inoculation Before Jenner” (Hebrew), Derech Yisrael b’Refuah (Jerusalem, 5730): 376-379; David Ruderman, “Some Jewish Responses to Smallpox Prevention in the Late Eighteenth and Early Nineteenth Centuries: A New Perspective on the Modernization of European Jewry,” Aleph 2 (2002): 111-144. 3. On the general risk of medical procedures (including the application of the principle of “shomer p’taim Hashem, God watches over the simpleton”) see Rabbi J. David Bleich, “Hazardous Medical Procedures,” Bioethical Dilemmas 2 (Southfield, MI, 2006): 239-275; David Shabtai and Raymond Sultan, “Metzitzah b’Peh: Paradigm for Halachic Risk Taking,” Jewish Medical Ethics 6:1 (December 2007): 26-48. 4. For a detailed analysis of the halachic aspects of vaccination, see Daniel Eisenberg, “The Ethics of Smallpox Vaccination,” at www.aish.com/societyWork/sciencenature/The_Ethics_of_Smallpox_Immunization.asp. 5. For a discussion on the liability of the physician and the government for damages incurred during vaccination, see Yigal Shafran, “Halakhic Attitudes Toward Immunization,” Tradition 26:1 (Fall 1991): 4-13 6. For a discussion on halachic aspects of preventative medicine, including vaccination, see James DiPoce and Shalom Buchbinder, “Preventative Medicine,” Journal of Halacha and Contemporary Society 42 (Fall 2001): 70-101. 7. For a discussion on the permissibility of autopsy after death from vaccination, see Mordechai Halperin, “The Laws of Saving Lives: The Teachings of Rabbi S. Z. Auerbach,” Jewish Medical Ethics 3:1 (January 1997): 44-49, esp. 46-47 and A. Steinberg, “Autopsy in the Case of Death After Vaccination” (Hebrew), Assia 59-60 (June 1997): 129-132. 8. Some invoke the principle of “shomer p’taim Hashem” as a possible reason to refrain from vaccinating (see, for example, Rabbi Shlomo Zalman Auerbach, Minchat Shlomo 2:29, letter dalet). On the application of this principle in halachah, see Rabbi Shlomo Duras, “Shomer P’taim Hashem,” Techumin 24 (5764): 445-454; the s\tatement of the Rabbinical Council of America on smoking available at http://www.rabbis.org/news/article.cfm?id=100808; Rabbi J. David Bleich, “Hazardous Procedures,” op. cit.; Shabtai and Sultan, op. cit. One could also apply the principle “tamim tihiyeh im Hashem Elokecha.” Rabbi Moshe Feinstein entertains the application of this principle as a basis for refraining from genetic testing for Tay-Sachs disease, but quickly rejects it citing how simple and effective genetic testing is to prevent the birth of a diseased child. Likewise, in the case of vaccination, the procedure is simple and the effectiveness is unquestioned. There is the aspect of risk, which is addressed above. 9. For a comprehensive review of the medical literature on the side effects of vaccines as well as on the association between vaccination and autism, see the Centers for Disease Control web site (www.cdc.gov).

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