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 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 : 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 -observant Jew. The Torah refusing vaccinations would never the removal of fluid from the pox of an gives license to the to heal have entered his mind. Unfortunately, afflicted , 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. 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 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 . tragic loss of two of his children to days of inoculation, the injections were

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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 , 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 who are vaccinations—including —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. While this argument is not without merit, the fewer people who get vaccinated, the less protective herd immunity will be. However, there is another factor to consider. Even among those who are vaccinated, small percentages do not achieve immunity. So if unvaccinated individuals contract a disease, they can spread it to this population. Furthermore, if the number of unvaccinated individuals rises, the possibil- ity of epidemic outbreaks exists—reminiscent of the pre- Jenner days. The recent outbreaks of measles attest to this fact. From January 1, 2008 through April 25, 2008, the CDC received a total of sixty-four reports of confirmed measles cases in nine states, the highest number for the same time period since 2001. Of the sixty-four people infected by the measles virus, only one had documentation of prior vaccination. Many of the cases occurred in children who were too young to be vaccinated or whose parents claimed exemption from vaccination due to religious or personal beliefs.1 One particular case affected the Jewish community in Cedarhurst, New York, just a few blocks from my home.2 Therefore, it is not only a personal decision to refuse vaccination; it is a decision that affects the entire commu- nity. It is thus within the Jewish community’s rights to man- date vaccination, for example, as a prerequisite for day school admission. One might argue that the assumption of risk for treat- ment of an existing medical condition is different from as- suming risk for preventative care, but even preventative care is considered a . When global epidemics of in- fectious disease were more prevalent, posekim were more willing to allow vaccination on Shabbat. But even today, in unique circumstances, posekim have permitted the viola- tion of Shabbat for the preventative procedure of vaccina- tion. For example, Rabbi allowed vaccination on Shabbat in the following limited scenario: If one did not receive the vaccination on Shabbat, and it would be a number of years before he would have that op- portunity again.3 Rabbi permitted a vaccine for tetanus to be given on Shabbat.4 While these cases are limited, they reflect the fact that posekim re- garded vaccination, though a preventative measure, as enough of an obligation to consider violating Shabbat. In the exceedingly rare cases of fatality possibly associ- ated with vaccination, posekim have addressed the issue of the permissibility of autopsies in order to clarify the cause of death and to perhaps prevent other . Rabbi Dr. Mordechai Halperin, the director of The Dr. Falk A smallpox inoculation sign from 1801. The more crude inocu- for Medical-Halachic Research in lation for smallpox was replaced in 1796 with Edward Jenner’s and the chief officer of for the Is- scientifically tested vaccine, which inoculated patients with the raeli Ministry of Health, recounts a 1992 case of an infant in cowpox virus in order to protect them from smallpox. who died shortly after receiving a hepatitis vaccina- tion. The Israeli Ministry of Health requested an autopsy tion. He made his decision partly because the odds of the of the infant, and Rabbi Halperin discussed the halachot of death being a result of the vaccine were small, coupled with the case with Rabbi Auerbach, who “gave an unambiguous decision that the postmortem should be carried out on ac- the fact that it was unlikely that the autopsy would produce 6 count of the dangers although, and he stressed this, it was useful results. clear to him that the danger was remote.”5 However, Rabbi To be sure, there are certain patients for whom vaccina- Yosef Shalom Elyashiv prohibited an autopsy in a similar tions are medically inadvisable, but such cases are excep- case involving an infant who died after receiving a vaccina- tions and each should be discussed individually with a

Winter 5769/2008 JEWISH ACTION I 13 physician. To forgo vaccination purely because of anecdotal 3. On the general risk of medical procedures (including claims is halachically irresponsible. the application of the principle of “shomer p’taim Hashem, Our success with vaccinations is the cause for our com- God watches over the simpleton”) see Rabbi J. David Bleich, placency. We in the twenty-first century have forgotten what “Hazardous Medical Procedures,” Bioethical Dilemmas 2 the lives of our ancestors were like—filled with sadness for (Southfield, MI, 2006): 239-275; David Shabtai and Raymond the children afflicted with paralysis from polio and with Sultan, “Metzitzah b’Peh: Paradigm for Halachic Risk Tak- ing,” 6:1 (December 2007): 26-48. 4. For a detailed analysis of the halachic aspects of vacci- nation, see Daniel Eisenberg, “The Ethics of Smallpox Vac- The Torah gives license to the physi- cination,” at http://www.aish.com/societyWork/sciencenature/The_Ethi cian to heal the sick, but does it give cs_of_Smallpox_Immunization.asp. license to the physician to bestow 5. For a discussion on the liability of the physician and the government for damages incurred during vaccination, illness upon the healthy, albeit for see Yigal Shafran, “Halakhic Attitudes Toward Immuniza- an ultimate cure? tion,” 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 Ha- mourning for children dying of smallpox and measles. These lacha and Contemporary Society 42 (Fall 2001): 70-101. occurrences are, fortunately, a thing of the past, due largely 7. For a discussion on the permissibility of autopsy after to the success of vaccination. May Hashem allow us to con- death from vaccination, see Mordechai Halperin, “The Laws tinue our success in the battle against infectious diseases. 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 Vacci- Notes nation” (Hebrew), Assia 59-60 (June 1997): 129-132. 1. Information from http://www.cdc.gov/Features/- 8. Some invoke the principle of “shomer p’taim Hashem” MeaslesUpdate/ as a possible reason to refrain from vaccinating (see, for ex- 2. “Health Officials Issue Measles Advisories in New ample, Rabbi Shlomo Zalman Auerbach, Minchat Shlomo York City, Long Island,” Associated Press, 8 April 2008, ac- 2:29, letter dalet). On the application of this principle in ha- cessed at http://www.nydailynews.com/ny_local/- lachah, see Rabbi Shlomo Kohen Duras, “Shomer P’taim 2008/04/08/2008-04-08_health_officials_issue_measles_ad Hashem,” Techumin 24 (5764): 445-454; the statement of the visorie.html Rabbinical Council of America on smoking available at 3. Minchat Shlomo 2:29, letter dalet; Shemirat Shabbat http://www.rabbis.org/news/article.cfm?id=100808; Rabbi J. Kehilchatah, chap. 32, n. 2 David Bleich, “Hazardous Procedures,” op. cit.; Shabtai and 4. “Vaccination for Tetanus on Shabbat” (Hebrew), Ha- Sultan, op. cit. One could also apply the principle “tamim ti- lachah U’Refuah 4 (Regensburg Institute, 5745): 179-180. In hiyeh im Hashem Elokecha.” Rabbi enter- the next volume, Dr. David Applebaum takes issue with tains the application of this principle as a basis for Rabbi Waldenberg’s permissive ruling and claims that since refraining from genetic testing for Tay-Sachs disease, but in this case the tetanus shot could be given after Shabbat, quickly rejects it citing how simple and effective genetic and would provide the same immunity, perhaps Shabbat vi- testing is to prevent the birth of a diseased child. Likewise, olation would not be necessary. in the case of vaccination, the procedure is simple and the 5. Mordechai Halperin, “The Laws of Saving Lives: The effectiveness is unquestioned. There is the aspect of risk, Teachings of Rabbi S. Z. Auerbach,” Jewish Medical Ethics 3:1 which is addressed above. (January 1997): 44-49, esp. 46-47 9. For a comprehensive review of the medical literature 6. A. Steinberg, “Autopsy in the Case of Death After Vac- on the side effects of vaccines as well as on the association cination” (Hebrew) Assia 59-60 (June 1997): 129-132 between vaccination and autism, see the Centers for Dis- ease Control web site (www.cdc.gov). For Further Reading: 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 Hur- witz, Sefer HaBrit (Jerusalem, 5750), 247ff.; H. J. Zimmels, Magicians, Theologians, and Doctors (London, 1952), 107-110; D. Margalit, “Smallpox Inoculation Before Jenner” (He- brew), Derech Yisrael b’Refuah (Jerusalem, 5730): 376-379; David Ruderman, “Some Jewish Responses to Smallpox Pre- vention in the Late Eighteenth and Early Nineteenth Cen- turies: A New Perspective on the Modernization of European Jewry,” Aleph 2 (2002): 111-144.

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