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Thursday, February 12, 2015

Vaccines in Halacha

UPDATED FEB. 2015: The News is full of Measles outbreaks. In 2013, according to the World Health Organization there were 400 deaths every single day due to measles. This is due to vaccines.

Yes, vaccines are to blame for the low measles fatality rates. In the year 2000, before a global acceleration of the measles vaccine, there were approximately 1500 deaths a day from Measles. And in 1980, before vaccination was widespread, there were more than 7000 deaths a day caused by measles. That is deaths. Per day.  Most of these deaths are children under the age of 5.

Due to the latest outbreak, and the increased vaccine discussion, I was asked to recirculate the article written on the occasion of the polio outbreak in Israel in 2013.

08/2013 There have been some recent reports in Southern Israel of the polio virus being discovered. As a result the Ministry of Health is encouraging all children born after January 1 2004 to receive a special inoculation, which is available for free. This has led to some discussion of vaccinations in general, and I would like to present the halachic perspective. At the end of the article we will discuss the polio vaccine specifically.

First, a word about polio, a disease which we are not familiar with, Boruch Hashem. Polio causes acute paralysis that can lead to permanent physical disability and even death. Before polio vaccine was available, 13,000 to 20,000 cases of paralytic polio were reported each year in the United States. Annual epidemics of polio often left victims—mostly children—in braces, crutches, wheelchairs, and, in serious cases, iron lungs. Many of the children that survived experienced life-long consequences from the disease.

It is important to note that almost all vaccines are not effective in 100% of the population, and therefore rely on a herd, meaning if everyone is inoculated there will not be enough carriers to infect those whom the vaccine did not work for.

Another vaccine that has been scrutinized lately is the MMR vaccine. MMR inoculates against measles, mumps and rubella, three potentially fatal disease. Some history is in order:
MMR was first linked to autism in The Lancet, 1998 by Dr. Andrew Wakefield and twelve coauthors. It was widely circulated and featured on 60 Minutes. However the science behind the study was suspect, and over the years 10 of the 12 coauthors withdrew their names. In February 2010 The Lancet retracted the article, and in March 2010 Dr. Wakefield lost his medical license due to having acted irresponsibly.

Additionally the main factor studied was Thimerosal, a mercury based ingredient that was used in vaccines. As of 2001 the Thimerosal was removed from almost all vaccines.

However, there is still much lingering confusion in the general populace, and much misinformation being spread purporting that the vaccine should not be given. This thinking has taken grip in many Orthodox communities, and unfortunately, over the years there have been outbreaks in Jewish enclaves of mumps and measles. These are diseases that can be fatal, and/or have lifelong effects on the health of the diseased.

Avoiding Pre-Existing Danger

There is a very clear commandment in the Torah to take preventative action to avoid danger – the obligation to build a Maakeh, agate around a rooftop, or anywhere from which one can fall. We find that this concept extends on a Torah level to be “exceedingly careful” to avoid all dangerous situations, food, and activities – (see CM 427).

We find many activities and foods that were prohibited by Chazal due to the possibility of danger, and the well-known adage that Chamira Sakanta Meisura, we are stricter with risk than prohibitions, underscores this.

There is some discussion in the poskim as to the risk factor needed to be considered a dangerous activity. According to all opinions if it is 50% or higher it is forbidden, and according to many a significant risk such as a 10% risk is prohibited as well.

However, we find that even when there is only a small chance of danger the action or food is prohibited, see IGM OC 2:100.

Rav Chaim Ozer Grodzinski wrote that although there is a rule of Shomer Pesaim Hashem, Hashem protects the foolish, which the Gemara uses as a rationale to explain risky behavior, that only applies when it’s a distant and minor concern (Achiezer 1:23). Others write that the rule only applies when the concern is by and large disregarded and ignored.

Proactive Healthy Action

Until now we have discussed avoiding existing dangerous situations. There is much less Halachic literature written about proactively protecting oneself from unsafe circumstances.

The most notable is the Rambam (Deos 4) who describes healthy living as part of Avodas Hashem, and therefore includes eating, sleeping and exercise habits as part of the overall service to Hashem.

The opinion of the Rambam (as understood by Rav Shlomo Zalman Auerbach) is that contemporary medical advice is to be the basis of what is considered healthy living.

There is also some discussion on the poskim regarding healthy people fleeing a smallpox epidemic, the Rema (YD:116:5) and the Mishna Berura quoting the Shelah (OC 576 MB 14) write that one must flee the town in which people are contracting smallpox.

Vaccination

So it would seem clear that there is an obligation to take steps to prevent and avoid disease, and presumably vaccinations would be required as well.

However vaccination is somewhat different than flight as it’s not inherently risk free. There is a very small possibility that the person receiving the inoculation will get sick as well.

When the smallpox vaccine was first invented, the Tiferes Yisroel (see commentary to Yoma 8:3) was asked whether one should be vaccinated.

The risk of vaccination (in his time 1/1000 fatality rate) was weighed against the risk of getting infected with smallpox, (at that time 30% of the population died due to smallpox) and he ruled that one should be vaccinated.

On the one hand, nowadays the risk factor of infection is statistically miniscule, due to the widespread use of vaccinations. On the other hand in order to perpetuate this we must continue to inoculate until there is worldwide eradication of any given disease, and the risk factor of becoming ill from the vaccine itself is scientifically unproven or negligible as well.

Therefore, many poskim conclude, an individual cannot be compelled to vaccinate their children (putting aside legal or school policy concerns). This is the opinion of Rav Shlomo Zalman Auerbach and Rav Neuwirth.

The Nishmas Avraham qualifies this by saying in the name of Rav Shlomo Zalman and Rav Neuwirth that inoculations should be strongly encouraged. Indeed, all the above poskim encouraged parents and doctors to vaccinate children.

In a much firmer stance, Rav Elyashiv, quoted by Rabbi Tatz in “Dangerous Disease & Dangerous Therapy,” says that all parents have an obligation to vaccinate as this is normative practice throughout the world, and is included in the parents’ basic obligation to care for their child. It would seem from the quote that he was very familiar with the scientific pros and cons and felt that until there was objective evidence to the contrary one must vaccinate to avoid danger; not vaccinating would be considered negligence on the part of the parent.

Additionally, Rav Elyashiv is quoted as ruling that parents of vaccinated children can insist that all other children in the class be vaccinated as well, so as to limit their exposure to disease.

There has been an ongoing discussion in Lakewood, NJ as to whether schools can insist that all children be vaccinated. After perusing the various statements, proclamations and psakim that have been issued over the last few years in the Lakewood controversy regarding immunizations, it seems clear that the (seemingly minority) opinions that do not support compulsory vaccinations are basing their psak, in part, on the fact that there is a portion of the medical community that is anti-vaccine, and the jury is still out on the issue. This is simply no longer true, and should be noted.

Additionally it should be noted that none of the Rabbonim involved discouraged vaccinations, they just felt the schools can’t mandate them.

In some states where it is legally mandated to vaccinate your children, there is the option of a religious waiver, where one can state their religion is against vaccinations. In light of all that has been discussed, according to all opinion it would seem incorrect to use a religious exemption, with Judaism being the religion.

The Current Polio Issue

So how about the current polio vaccine being recommended in Israel? This is a little different, and may not be subject to the above discussion.

In a nutshell as I understand it:

It seems that all children, once vaccinated, cannot contract polio. They can however still be carriers, and infect other unvaccinated people. Strains of polio have been found in sewers in Southern Israel, (much of the Muslim world does not vaccinate) and can therefore infect unvaccinated people. The current campaign introduces a weakened live strain of the virus into an already inoculated child, who then will not get sick, but will fight the virus and not be a carrier, and thus help eradicate the virus completely.

Although there doesn’t seem to be any statistical risk to the child getting the live vaccine, they cannot come into close contact with immune-deficient people. They also don’t gain anything, and there are (unsubstantiated by me) rumors of a very minute percentage of these children becoming ill as well.

The question then becomes a hashkafic one: Do I have to compromise, even minutely, my health or even convenience for the greater good? Furthermore, Should I compromise the health of some immuno-deficient people I may come in contact with for the greater good?

Something to think about, and if applicable discuss with your Rav.

May we merit the days when disease and illness will cease to exist!

In writing this article I leaned heavily on information presented by Rabbi Bush in Hakirah vol. 9, and an article by the Institue of Dayanim, pub. 17th Tamuz 5772, as well as information provided by the Ministry of Health.

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Meet Rabbi Tzvi Hirsch Haber

Rabbi Tzvi Hirsch HaberRabbi Tzvi Hirsch Haber is sought after by all who know him for his Halachic and practical advice. His keen ability to put complicated matters into a digestible perspective coupled with his ability to get the facts, make him the perfect blogger to help us all “Do It Right”.

A native of Buffalo, NY, Rabbi Tzvi Hirsch Haber spent his childhood globetrotting with his family. His pioneering spirit first surfaced in Melbourne, Australia, where he was excited to be a member of the opening class of Mesivta Bnei Torah. From Australia the Haber family settled down in Monsey, NY. Ever the maverick, Tzvi promptly left home to study in Yeshiva Ohr Hameir in Peekskill, where he became a mainstay of the Yeshiva, and inspired his younger brothers as well as several friends from the Mesivta in Melbourne to follow him. He then joined his chaburah in Jerusalem, first at the Mir Yeshiva and then at the Bais Medrash of Rav Dovid Soloveitchik, a senior scion of the famed Brisk dynasty. As his globetrotting family returned to Jerusalem, Tzvi returned to the US, to freeze in the famed, yet comparatively chilled Beth Medrash Govoha of Lakewood.

 In 2004 he met his wife, Suzanne Schor, a native of the warmer Los Angeles climate, and the couple settled in Lakewood, where he focused his pioneering and independent strengths on the study of Halacha, or Jewish law. His innovative spirit and innate ability to help others seeking to clarify the finer points of Judaism and integrate them into their daily lives inspired his decision to commute daily from Lakewood to the Lower East Side of Manhattan in order to bask in the day to day exposure to the world renowned Posek, HaRav David Feinstein. The daily commute was more than compensated for when he received Semicha from Rav Feinstien and the Kollel L’Torah U’lhorah (a division of Mesivta Tifereth Jerusalem) in Tamuz 5768, June 2008.

In August 2009, the Habers moved west, heading toward Los Angeles where Rabbi Haber joined the LINK-LA Kollel. After being an active member of the Kollel for several years, he joined the business world, however he is still actively involved in teaching and learning in LA.

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Rabbi Haber is now living in the La Brea section of Los Angeles with his wonderful family. He can be contacted at tzvi@torahlab.org