Nature&Science By Edward Reichman Halachic Aspects of Vaccination Perhaps it is because we live in When potential relief from the horrors smallpox and beseeching the rabbis of twenty-first century America, a coun- of the disease came on the horizon, his generation to allow inoculation. try largely immune from true epi- there must have been unabashed ex- However, the treatment was con- demics, that we take vaccination for citement. The cure, or, more accu- sidered controversial at the time, as granted and some parents even con- rately, the mechanism of disease never in the history of mankind had sider not vaccinating their children. A prevention, however, was unique in the one taken a healthy individual and in- Jew living in the eighteenth century history of medicine: it required expos- jected him with the very cause of an would have longed for respite from the ing healthy individuals to disease, illness, even if the objective was to relentless onslaught of diseases, and hopefully a mild form, in order to pre- prevent a more severe disease. This could only have dreamed of having a vent the development of a more seri- unique treatment posed a dilemma for way to prevent them. The thought of ous disease. The procedure involved the Torah-observant Jew. The Torah refusing vaccinations would never the removal of fluid from the pox of an gives license to the physician to heal have entered his mind. Unfortunately, afflicted patient, and the subsequent the sick, but does it give him license to nowadays, as a result of misleading in- injection of that virulent fluid into the bestow illness upon the healthy, albeit formation, some parents are confused body of a healthy individual. Scientists for an ultimate cure? The debate about about the issue and do not realize the believed that the healthy person in- the medical and theological aspects of importance of vaccinations. A cursory jected with the fluid would develop a smallpox inoculation occupied a sig- review of the origins of vaccination in mild, non-fatal form of smallpox, and nificant chapter in eighteenth- and medical and rabbinical literature may would therefore be spared the likeli- nineteenth-century history. provide some perspective on the issue. hood of fatality if later exposed to the Rabbis of that time debated the is- In the late eighteenth century, spontaneous form. This was indeed sues and were well aware of the risks smallpox decimated the population of the case the majority of the time, but associated with vaccination. Rabbi Is- Europe. Millions of people died from the procedure was not without risk; rael Lifschutz, author of the Tiferet Yis- the disease, and a high percentage of some of those inoculated developed rael commentary on the Mishnah, children were afflicted. In the eigh- the severe form of the disease, and argued in favor of inoculation despite teenth century alone, an estimated died as a result (an estimated 0.5 to 2 its known risks. In his view, the bene- 400,000 Europeans died each year. percent). In fact, there is a tombstone in Long Island, New York, with the fol- fits clearly exceeded the risks. Other lowing epitaph: prominent rabbis advocated vaccina- Dr. Reichman is an associate professor of tion as well, including Rabbi emergency medicine and an associate pro- In Memory of Peleg, Mordechai Banet (1753-1829), Rabbi fessor of philosophy and history of medi- Son of Thomas and Mary Conklin, Eliezer Fleckeles (1754-1826) and Rabbi cine at the Albert Einstein College of who died of the smallpox inoculation Medicine of Yeshiva University. He re- Jan. 27th, 1788, aged 17 years Ishmael HaKohen (1723-1811). ceived his semichah from the Rabbi Isaac In 1785, Rabbi Avraham ben Shlomo An additional halachic issue arose Elchanan Theological Seminary. He writes Nansich published a small pamphlet with regard to the practical dissemina- and lectures widely in the field of Jewish entitled “Aleh Terufah,” detailing the tion of the inoculation. In the early medical ethics. tragic loss of two of his children to days of inoculation, the injections were 10 I JEWISH ACTION Winter 5769/2008 performed by barber-surgeons, who 200 years have passed since Jenner’s cure and prevent disease remains in traveled from town to town. They discovery, and the effectiveness of vac- full force, despite the risks. To be sure, often spent only a few hours in each cination is now beyond question. In each treatment requires its own risk- location. The question therefore arose fact, the discovery of vaccination is on benefit statistical analysis. as to whether one could receive the in- virtually every top ten list of the great- Anecdotal accounts of vaccinations oculation on Shabbat, if that happened est discoveries in the history of medi- leading to other conditions, such as to be the only time it was offered. The cine, appearing as number one on autism, do exist. But these are not halachic discussions touched on two many of them. While there is no way well-documented, scientifically proven issues. The first issue related to the to know how many lives have been side effects. To date, these claims have exact nature of the prohibition associ- saved globally as a result of vaccina- not been substantiated by rigorous sci- ated with the injection. Halachic dis- tions for diseases such as smallpox, entific study. In 2004, the Institute of tinctions were drawn between diphtheria, measles, polio, pneumococ- Medicine performed a thorough study injections made under the skin (subcu- cus and influenza, tens of millions on the hypothesis that vaccines, and, in taneous), as opposed to those made di- would be a very conservative estimate. particular, the mercury they contained, rectly into the vein (intravenous). The Indeed, smallpox, the first disease for were causally related to autism. Its second, more fundamental, issue was which vaccination was used, has been published findings, entitled “Immu- the determination of the halachic sta- virtually eradicated from the face of nization Safety Review: Vaccines and tus of the healthy patient receiving the the earth. Autism,” concluded that the body of injection. The violation of Shabbat is However, while the side effects of epidemiological evidence rejects a permitted only for patients who are vaccinations—including death—are causal relationship between mercurial- technically considered ill, and the level rare, they are also well documented. containing vaccines and autism. The of violation allowed is commensurate Despite these foreseen consequences, web site of the Centers for Disease with the severity of the illness. While scientific research has proven that the Control and Prevention (CDC) states, patients in need of receiving inocula- risk-benefit analysis weighs very heav- “Carefully performed scientific studies tion are not technically ill, the debate ily in favor of vaccination. The side ef- have found no relationship between was whether they should MMR [measles, mumps nonetheless be consid- and rubella] vaccine and ered in the halachic cate- autism.” Time Magazine gory of a “choleh she’ain recently devoted its cover bo sakanah” (one experi- story to addressing the encing a non-life-threat- autism concern, and ening illness), by virtue reached the same conclu- of their presence in an sion (“How Safe Are Vac- endemic area of life- cines?” by Alice Park, June threatening disease (see, 2, 2008). for example, Teshuvah Furthermore, unvacci- Meahavah 1:134; Zecher nated individuals expose Yehosaf, OC 104; Shu”t themselves to additional Vela’asher Amar 15). This risk for vaccine-associated categorization of the pa- diseases. It is often tient would allow the vio- claimed, however, that lation of some their risk is low due to prohibitions in the provi- A 1966 photo shows writing on the side of a clinic annex building herd immunity, a type of sion of treatment. If the in East Pakistan (now Bangladesh), indicating the World Health immunity that occurs patient receiving the in- Organization’s (WHO) goal of eradicating smallpox. The world’s when the vaccination of a oculation was not as- last case of smallpox was documented in Africa in 1977, and in large portion of a cribed this status, no 1980 the WHO declared the global eradication of smallpox due to population (or herd) Shabbat violation would a worldwide vaccination campaign. Illustrations courtesy of the Cen- provides protection to be permitted. After much ters for Disease Control and Prevention unvaccinated individuals. deliberation, a number of Herd immunity theory posekim allowed the inoculation of fects must be viewed in the context of proposes that, in diseases passed from healthy individuals on Shabbat, which general medical practice. The issue of person to person, it is more difficult to entailed possible Shabbat violation, in assuming risk and self-endangerment maintain a chain of infection when order to protect them from exposure is the substance of many halachic dis- large numbers of a population are to smallpox. cussions, but the assumption of some immune. The more immune The more crude inoculation for risk in the pursuit of medical treat- individuals present in a population, the smallpox was soon replaced with the ment is an accepted fact. There is ar- lower the likelihood that a susceptible scientifically tested vaccination of Ed- guably not a single form of treatment, person will come into contact with ward Jenner, which inoculated patients from Tylenol to chemotherapy, which someone who is infected. Thus, since with the cowpox virus in order to pro- is free of side effects—many of them most of the people in a community are tect them from smallpox. More than serious. Yet the obligation to seek a vaccinated against diseases, it is less 12 I JEWISH ACTION Winter 5769/2008 likely that viruses or bacteria will flourish there and there- fore less likely for an unvaccinated individual to contract these diseases.