Determining whether, and when, to get one's children vaccinated has become an increasingly controversial decision, often leaving parents fearful of making the “wrong” choice. Part of the challenge stems from the fact that what is rationally optimal for an individual is inherently at odds with the best outcome for the community, meaning that if everyone acted out of self-interest with respect to pediatric vaccines, communal health would suffer significantly. Given these tensions, the issue of pediatric vaccines benefits greatly from the nuanced assessment of Catholic social teaching. Specifically, the Pontifical Council for Justice and Peace's “four permanent principles” of human dignity, the common good, subsidiarity, and solidarity highlight the issues involved and help parents navigate this significant medical choice with a more informed conscience and a greater sense of their moral responsibilities. The end result is a fruitful alignment between Catholic social teaching and ethics in ordinary life.
1 Johnson, Kelly S., “Catholic Social Teaching,” in Gathered for the Journey: Moral Theology in Catholic Perspective, ed. McCarthy, David Matzko and Lysaught, M. Therese (Grand Rapids, MI: William B. Eerdmans, 2007), 225–40, at 232.
2 The author would like gratefully to acknowledge the assistance of his wife, Kate Kelly, CPNP, whose insights and experience as a pediatric nurse practitioner led to many conversations informing this article and strengthening its argument.
3 Cahill, Lisa, Theological Bioethics: Participation, Justice, Change (Washington, DC: Georgetown University Press, 2005), 18.
4 To give just one example, fears of polio were so strong when Jonas Salk was developing his famous vaccine that local health officials had no trouble securing volunteers for the tests of the as-yet unproven vaccine, and once it was announced that the tests were successful, “people wept openly with relief.” Oshinsky, David M., Polio: An American Story (Oxford: Oxford University Press, 2005), 190, 203.
5 Plotkin, Susan L. and Plotkin, Stanley A., “A Short History of Vaccination,” in Vaccines, ed. Plotkin, Stanley A., Orenstein, Walter A., and Offit, Paul A., 6th ed. (St. Louis: Elsevier Saunders, 2013), 1–13. In terms of early objections, the famed Boston minister Cotton Mather encountered stiff resistance when he encouraged an early inoculation practice called variolation to combat a smallpox epidemic in the 1720s, “to the point at which a grenade was thrown into his house in objection!” Likewise, Louis Pasteur's use of a rabies vaccine to protect two children who had been bitten by rabid dogs “left people aghast” because he used the actual (although weakened) rabies virus and not a substitute pathogen. Ibid., 2, 5.
6 Macklin, Ruth and Greenwood, Brian, “Ethics and Vaccines,” in The Vaccine Book, ed. Bloom, Barry R. and Lambert, Paul-Henri (San Diego: Academic Press, 2003), 119–27, at 120–21; Grady, Christine, “Ethics of Vaccine Research,” in Research Ethics, ed. Iltis, Ana Smith (New York: Routledge, 2006), 22–31, esp. 22–23.
7 On HeLa cells and the polio vaccine, see Skloot, Rebecca, The Immortal Life of Henrietta Lacks (New York: Crown Publishers, 2010), 93–97. The book as a whole chronicles the questionable ethics involved in the initial procurement and creation of HeLa cells. On the issue of vaccines derived from aborted fetuses, see Pontifical Academy for Life, Moral Reflections on Vaccines Prepared from Cells Derived from Aborted Human Foetuses (2005), http://www.academiavita.org/_pdf/documents/pav/moral_relflections_on_vaccines_en.pdf.
8 Eiser, Arnold R., The Ethos of Medicine in Postmodern America: Philosophical, Cultural, and Social Considerations (Lanham, MD: Lexington, 2014), 143–44, 147. See also Lysaught, M. Therese, “Respect: Or, How Respect for Persons Became Respect for Autonomy,” Journal of Medicine and Philosophy 29, no. 6 (2004): 665–80.
9 National Center for Immunization and Respiratory Diseases, “Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger, United States, 2017,” Centers for Disease Control and Prevention, last modified February 6, 2017, https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html.
10 See Orenstein, Walter A. and Hinman, Alan R., “The Immunization System in the United States—The Role of School Immunization Laws,” Vaccines 17, supplement 3 (Oct. 29, 1999): S19–S24, esp. S22–S23.
11 The number of diseases targeted by pediatric vaccines increased more than twofold from 1983 to 2005. Largent, Mark A., Vaccine: The Debate in Modern America (Baltimore: Johns Hopkins University Press, 2012), 15.
12 Omer, Saad B., Pan, William K. Y., Halsey, Neal A., Stokley, Shannon, Moulton, Laurence H., Navar, Ann Marie, Pierce, Mathew, and Salmon, Daniel A., “Nonmedical Exemptions to School Immunization Requirements: Secular Trends and Association of State Policies with Pertussis Incidence,” Journal of the American Medical Association 296, no. 14 (Oct. 11, 2006): 1757–63; Liz Szabo, “Refusing Kids’ Vaccine More Common among Parents,” USA Today, last modified May 3, 2010, http://usatoday30.usatoday.com/news/health/2010-05-04-vaccines04_ST_N.htm.
13 Maggie Fox, “Vaccine Rates Are Up, But So Are Refusals,” NBC News, last modified January 19, 2018, https://www.nbcnews.com/health/health-news/vaccine-rates-are-so-are-refusals-n838811.
14 Offit, Paul A., Deadly Choices: How the Anti-Vaccine Movement Threatens Us All (New York: Basic Books, 2011), 2–11.
15 Ibid., 27–44.
16 Ibid., 91–92.
17 Ibid., 93–96; Largent, Vaccine, 73–74. Eggertson, Laura, “Lancet Retracts 12-Year-Old Article Linking Autism to MMR Vaccines,” Canadian Medical Association Journal 182, no. 4 (March 2010): E199–E200; Editors of The Lancet, “Retraction—Ileal-Lymphoid-Nodular Hyperplasia, Non-specific Colitis, and Pervasive Developmental Disorder in Children,” The Lancet 375, no. 9713 (February 2, 2010): 445.
18 Largent, Vaccines, 75–76, 83–87, 88–93. Largent notes that roughly 20 percent of US parents believe that vaccines can cause autism (68).
19 Offit, Paul and Bell, Louis M., Vaccines: What You Should Know, 3rd ed. (Hoboken, NJ: John Wiley, 2003), 18–25.
20 National Center for Immunization and Respiratory Diseases, “Possible Side-Effects from Vaccines,” Centers for Disease Control and Prevention, last modified May 8, 2017, https://www.cdc.gov/vaccines/vac-gen/side-effects.htm.
21 Offit, Paul A. and Moser, Charlotte A., Vaccines and Your Child: Separating Fact from Fiction (New York: Columbia University Press, 2011), 175.
22 Centers for Disease Control and Prevention, “Suspension of Rotavirus Vaccine after Reports of Intussusception—United States, 1999,” Morbidity and Mortality Weekly Report 53, no. 34 (September 3, 2004): 786–89; Zanardi, L. R., Haber, P., Mootrey, G. T., Niu, M. T., and Wharton, M., “Intussusception among Recipients of Rotavirus Vaccine: Reports to the Vaccine Adverse Event Reporting System,” Pediatrics 107, no. 6 (June 2001): E97.
23 National Center for Immunization and Respiratory Diseases, “Possible Side-Effects.”
24 Offit and Bell, What You Should Know, 88, 90.
25 Ibid., 22.
26 Oshinsky, Polio, 161.
27 Offit and Moser, Vaccines and Your Child, 149; Offit and Bell, What You Should Know, 49; National Center for Immunization and Respiratory Diseases, “Possible Side-Effects.”
28 Offit and Moser, Vaccines and Your Child, 18.
29 Statistics based on author's own calculations: 20,000 birth defects among 4,257,850 live births. Vital Statistics of the United States 1960, vol. 1, Natality (Hyattsville, MD: United States Department of Health, Education, and Welfare, 1964), section 1.
30 Madsen, Kreesten Meldgaard, Hviid, Anders, Vestergaard, Mogens, Schendel, Diana, Wohlfahrt, Jan, Thorsen, Poul, Olsen, Jørn, and Melbye, Mads, “A Population-Based Study of Measels, Mumps, and Rubella Vaccination and Autism,” New England Journal of Medicine 347, no. 19 (Nov. 7, 2002): 1477–82, at 1479–80. The percentage and ratio statistics presented here are based on the authors’ own calculations: 263 cases of autistic disorder and 345 cases of “other autistic-spectrum disorders” among vaccinated children (total of 608) out of 440,655 vaccinated children.
31 Madsen et al., 1480–82; see also Largent, Vaccine, 122.
32 For an overview of the effects of the recommended vaccines in relation to the dangers of the diseases they prevent and the possibilities of side effects, see Offit and Bell, What You Should Know, 33–86. For the rotavirus, hepatitis A, and flu vaccines that have since been incorporated into the recommendations, see Offit and Moser, Vaccines and Your Child, 134–41, 154–64, and 188–94.
33 Fine, Paul, Eames, Ken, and Heymann, David L., “‘Herd Immunity’: A Rough Guide,” Clinical and Infectious Diseases 52, no. 7 (April 1, 2011): 911–16. On the eradication of smallpox, see Tucker, Jonathan B., Scourge: The Once and Future Threat of Smallpox (New York: Grove Press, 2001), 39–138.
34 Offit and Bell describe this practice by referring to the difference between “seen” and “unseen” risks. The risks we can see (e.g., vaccine side effects experienced immediately) often weigh more heavily on us than the risks we cannot see (e.g., the symptoms of a disease contracted in the future), even though the latter are often worse. Offit and Bell, What You Should Know, 21–22.
35 This is an important factor in the increase in refusals of pediatric vaccines for nonmedical reasons, as “lower perceived risk of contracting a vaccine-preventable disease, lower perceived importance of vaccine-preventable disease, [and] lower perceived vaccine safety and effectiveness” have all been associated with vaccine refusals and delays. Salmon, Daniel A., Dudley, Matthew Z., Glanz, Jason M., and Omer, Saad B., “Vaccine Hesitancy Causes, Consequences, and a Call to Action,” Vaccine 33, supplement 4 (Nov. 2015): D66–D71, at D68.
36 For more on the notion of a prisoner's dilemma, see Steven Kuhn, “Prisoner's Dilemma,” Stanford Encyclopedia of Philosophy, last modified August 29, 2014, https://plato.stanford.edu/entries/prisoner-dilemma/.
37 Macklin and Greenwood, “Ethics and Vaccines,” 125–26.
38 For a succinct account of Catholic social teaching's theological anthropology, see Heyer, Kristin E., “Catholics in the Political Arena: How Should Faith Inform Catholic Voters and Politicians,” in Catholics and Politics: The Dynamic Tension between Faith and Power, ed. Heyer, Kristen E., Rozell, Mark J., and Genovese, Michael A. (Washington, DC: Georgetown University Press, 2008), 61–72, at 62–63.
39 See Coleman, John, “Development of Church Social Teaching,” in Official Catholic Social Teaching, ed. Curran, Charles E. and McCormick, Richard A. (New York: Paulist Press, 1986), 169–87.
40 For instance, the Pontifical Council for Justice and Peace identifies four “permanent principles,” the United States Conference of Catholic Bishops specifies seven “themes,” Thomas Massaro articulates nine themes, and William Byron describes ten principles. Pontifical Council for Justice and Peace, Compendium of the Social Doctrine of the Church (Vatican City: Libreria Editrice Vaticana, 2004), §160; United States Conference of Catholic Bishops, “Seven Themes of Catholic Social Teaching,” last modified 2005, http://www.usccb.org/beliefs-and-teachings/what-we-believe/catholic-social-teaching/seven-themes-of-catholic-social-teaching.cfm; Massaro, Thomas, Living Justice: Catholic Social Teaching in Action, 2nd classroom ed. (Lanham, MD: Rowman & Littlefield, 2012), 79–117; Byron, William J., “Ten Building Blocks of Catholic Social Teaching,” America 179, no. 13 (Oct. 31, 1998): 9–12.
41 Pontifical Council for Justice and Peace, Compendium, §160 (emphasis in the original); see also §§105–96 more broadly.
42 Byron, “Ten Building Blocks,” 10; Pontifical Council for Justice and Peace, Compendium, §160.
43 Johnson, “Catholic Social Teaching,” 228.
44 Gaudium et Spes §12, 19, in Tanner, Decrees of the Ecumenical Councils, 2:1075–76, 1079; Massaro, Living Justice, 81.
45 Massaro, Living Justice, 82; cf. Byron, “Ten Building Blocks,” 11.
46 Respect for life is sometimes treated as a distinct principle, and sometimes identified as an element of the principle of human dignity. Byron, “Ten Building Blocks,” 10; cf. USCCB, “Seven Themes”; Massaro, Living Justice, 81–82.
47 Pope John Paul II, The Gospel of Life (Evangelium Vitae), March 25, 1995, §§2, 8, http://w2.vatican.va/content/john-paul-ii/en/encyclicals/documents/hf_jp-ii_enc_25031995_evangelium-vitae.html.
48 Pope Leo XIII, On Capital and Labor (Rerum Novarum), May 15, 1891, §40, http://w2.vatican.va/content/leo-xiii/en/encyclicals/documents/hf_l-xiii_enc_15051891_rerum-novarum.html; see also Pope John XXIII, Peace on Earth (Pacem in Terris), April 11, 1963, §§10–27, http://w2.vatican.va/content/john-xxiii/en/encyclicals/documents/hf_j-xxiii_enc_11041963_pacem.html; Gaudium et Spes, §27, in Tanner, Decrees of the Ecumenical Councils, 2:1085–86.
49 Pope John Paul II, After One Hundred Years (Centesimus Annus), May 1, 1991, §41, http://w2.vatican.va/content/john-paul-ii/en/encyclicals/documents/hf_jp-ii_enc_01051991_centesimus-annus.html; cf. Kant, Immanuel, Groundwork of the Metaphysics of Morals, trans. and ed. Gregor, Mary and Timmermann, Jens, rev. ed. (Cambridge: Cambridge University Press, 2012), 41.
50 See Pacem in Terris, §11.
51 Thomas Aquinas, Summa Theologiae, II-II, q. 26, a. 8, c and ad 1.
52 Scholars tend to put these passages in a broader context, which includes statements from Jesus condemning those who would ignore all obligations to family members, to assert that the central message is a rejection of the absolutization of kinship ties rather a dismissal of those ties altogether. Barton, Stephen C., Discipleship and Family Ties in Mark and Matthew (Cambridge: Cambridge University Press, 1994), 169–70; Rubio, Julie Hanlon, A Christian Theology of Marriage and Family (New York: Paulist Press, 2003), 49–54.
53 See Evangelium Vitae, §§58–63.
54 Pontifical Academy for Life, Moral Reflections on Vaccines; for an updated listing, see “USA and Canada Aborted Fetal Cell Line Products and Ethical Alternatives,” Children of God for Life, last modified October 2017, https://cogforlife.org/wp-content/uploads/vaccineListOrigFormat.pdf.
55 Pontifical Academy for Life, Moral Reflections on Vaccines.
56 Gaudium et Spes, §26, in Tanner, Decrees of the Ecumenical Councils, 2:1084.
57 Massaro, Living Justice, 84.
58 Ibid., 85–86; see Hollenbach, David, The Common Good and Christian Ethics (Cambridge: Cambridge University Press, 2002), 11–12, 195–200.
59 Scheid, Daniel P., The Cosmic Common Good: Religious Grounds for Ecological Ethics (Oxford: Oxford University Press, 2016), esp. 15–44; see also Pope Francis, On Care for Our Common Home (Laudato Si’), May 24, 2015, §§23, 156, http://w2.vatican.va/content/francesco/en/encyclicals/documents/papa-francesco_20150524_enciclica-laudato-si.html; Pope John Paul II, “Peace with God the Creator, Peace with All Creation” (Message of His Holiness John Paul II for the Celebration of the World Day of Peace 1 January 1990), December 8, 1989, §15, https://w2.vatican.va/content/john-paul-ii/en/messages/peace/documents/hf_jp-ii_mes_19891208_xxiii-world-day-for-peace.html.
60 Hollenbach, The Common Good and Christian Ethics, 18.
61 See Kant, Groundwork of the Metaphysics of Morals, 17–18.
62 Massaro, Living Justice, 86.
63 One exception might be an accident at one of Merck's vaccine production sites that leaked a significant amount of a toxic preservative into the watershed near Philadelphia in 2006. This is not an indication of the normal risk of vaccines, however. Gregory Roumeliotis, “Blunder at Merck's Biggest Production Site Pollutes Creek,” Biopharma-Reporter, last modified July 19, 2008, https://www.biopharma-reporter.com/Article/2006/07/06/Blunder-at-Merck-s-biggest-production-site-pollutes-creek.
64 Martinez, Jose Luis, “Environmental Pollution by Antibiotics and Antibiotic Resistance Determinants,” Environmental Pollution 157, no. 11 (Nov. 2009): 2893–2902; Singer, Randall S., “Antibiotic Resistance—The Interplay between Antibiotic Use in Animals and Human Beings,” Lancet Infectious Diseases 3 (Jan. 2003): 47–48.
65 Pontifical Council for Justice and Peace, Compendium, §162.
66 Pope Pius XI, On the Reconstruction of the Social Order (Quadragesimo Anno), May 15, 1931, §80, http://w2.vatican.va/content/pius-xi/en/encyclicals/documents/hf_p-xi_enc_19310515_quadragesimo-anno.html.
67 Pope Benedict XVI, On Integral Human Development (Caritas in Veritate), June 29, 2009, §57, http://w2.vatican.va/content/benedict-xvi/en/encyclicals/documents/hf_ben-xvi_enc_20090629_caritas-in-veritate.html.
68 See USCCB, “Seven Themes”; Massaro, Living Justice, 87–89.
69 Centesimus Annus, §13. Indeed, the Second Vatican Council proclaimed the family “the first and vital cell of society’ (“prima et vitalis cellula societas”). Second Vatican Council, Decree on the Apostolate of the Laity (Apostolicam Actuositatem) §11, in Tanner, Decrees of the Ecumenical Councils, 2:989.
70 Gaudium et Spes, §17, in Tanner, Decrees of the Ecumenical Councils, 2:1078.
71 Pope John Paul II, The Splendor of Truth (Veritatis Splendor), §§35–45, August 6, 1993, http://w2.vatican.va/content/john-paul-ii/en/encyclicals/documents/hf_jp-ii_enc_06081993_veritatis-splendor.html.
72 Caritas in Veritate, §43. This idea is also treated as its own separate principle or theme, but it has a close affiliation with the principle of subsidiarity because one of the basic rights used to illustrate this point is the right to private property, a social institution that the principle of subsidiarity explicitly seeks to defend. USCCB, “Seven Themes”; Massaro, Living Justice, 92–95; see Pope John XXIII, Encyclical, Mater et Magistra, May 15, 1961, §117, http://w2.vatican.va/content/john-xxiii/en/encyclicals/documents/hf_j-xxiii_enc_15051961_mater.html.
73 Centesimus Annus, §51.
74 Pontifical Council for Justice and Peace, Compendium, §193; Bilgrien, Marie Vianney, Solidarity: A Principle, an Attitude, a Duty? Or the Virtue for an Interdependent World? (New York: Peter Lang, 1999), 1.
75 Pope John Paul II, On Social Concern (Sollicitudo Rei Socialis), December 30, 1987, §38, http://w2.vatican.va/content/john-paul-ii/en/encyclicals/documents/hf_jp-ii_enc_30121987_sollicitudo-rei-socialis.html.
76 This is best seen in the identification of solidarity as the cure for the problem of structural sin. Sollicitudo Rei Socialis, §40; see also Daly, Daniel J., “Structures of Virtue and Vice,” New Blackfriars 92, no. 1039 (May 2011): 341–57, at 348.
77 The preferential option for the poor is sometimes identified as a distinct principle of Catholic social teaching, but concern for the poor is also highlighted as a central component of the principle of solidarity as well, so there is a natural affinity between the two. USCCB, “Seven Themes”; Massaro, Living Justice, 113–16; Byron, “Ten Building Blocks,” 5–6; cf. Sollicitudo Rei Socialis, §§39, 45, 46.
78 Sobrino, Jon, “Bearing with One Another in Faith,” in Sobrino, Jon and Pico, Juan Hernández, Theology of Christian Solidarity, trans. Berryman, Phillip (Maryknoll, NY: Orbis Books, 1985), 5–6.
79 Ibid., 37; Juan Hernández Pico, “Solidarity with the Poor and the Unity of the Church,” in Sobrino and Pico, Theology of Christian Solidarity, 87–88.
80 There are also risks for those who have been vaccinated, as vaccine immunity is not typically 100 percent effective in 100 percent of the people who receive a given vaccine. The risks of contracting the disease after vaccination, however, are lower.
81 Berezin, Mabel and Eads, Alicia, “Risk Is for the Rich? Childhood Vaccination Resistance and a Culture of Health,” Social Science and Medicine 165 (September 2016): 233–45; Smith, Philip J., Chu, Susan Y., and Barker, Lawrence E., “Children Who Have Received No Vaccines: Who Are They and Where Do They Live?,” Pediatrics 187, no. 1 (January 2004): 187–95; Reich, Jennifer A., “Neoliberal Mothering and Vaccine Refusal: Imagined Gated Communities and the Privilege of Choice,” Gender and Society 28, no. 5 (October 2014): 679–704, at 680; Carrel, Margaret and Bitterman, Patrick, “Personal Belief Exemptions to Vaccinations in California: A Spatial Analysis,” Pediatrics 136, no. 1 (July 2015): 80–88, at 86.
82 Berezin and Eads, “Risk Is for the Rich?,” 240.
83 Pontifical Council for Justice and Peace, Compendium, §193 (emphasis in the original).
84 Centers for Disease Control and Prevention, “State School Immunization Requirements and Vaccine Exemption Laws,” last modified February 2017, https://www.cdc.gov/phlp/docs/school-vaccinations.pdf.
85 Walter Orenstein, the former head of the Centers for Disease Control and Prevention's National Immunization Program, has argued that “in some places, it's … easier to get an exemption than to get your child vaccinated.” Quoted in Offit, Deadly Choices, 196.
86 The principle of subsidiarity developed in response to the totalitarian centralization of government in some European countries between the First and Second World Wars, proposing a form of restraint on these governments’ overreach into people's lives. Massaro, Living Justice, 90–91.
87 Caritas in Veritate, §58 (emphasis in the original).
88 Gerald J. Beyer, “What Ryan Missed,” America, last modified June 4, 2012, http://americamagazine.org/issue/5143/100/what-ryan-missed.
89 See again Pontifical Academy for Life, Moral Reflections on Vaccines.
90 Wang, Eileen, Clymer, Jessica, Davis-Hayes, Cecilia, and Buttenheim, Alison, “Nonmedical Exemptions from School Immunization Requirements: A Systemic Review,” American Journal of Public Health 104, no. 11 (November 2014): e62–e84.
91 A good example of this distinction can be found in Delaware's compulsory vaccination laws, which permit religious exemptions but require parents to sign a legally binding document affirming that the belief “is not a political, sociological, or philosophical view of a merely personal moral code.” 14 Del. C. §131(a)(6), quoted in Centers for Disease Control and Prevention, “State School Immunization Requirements.”
92 See United States Conference of Catholic Bishops, Forming Consciences for Faithful Citizenship (Washington, DC: United States Conference of Catholic Bishops, 2015), §33.
93 One version of the precautionary principle is stated as follows: “Activities that present an uncertain potential for significant harm should be prohibited unless the proponent of the activity shows that it presents no appreciable risk of harm.” Kelly, Kevin, What Technology Wants (New York: Penguin Books, 2010), 247; see also 246–51 more generally.
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