The Vaccine Blog

Should there be stricter regulations on non-medical vaccine exemptions?

Should there be stricter regulations on vaccine exemptions?

Vaccine exemptions


They`ve been among the most hotly debated aspects of vaccination globally. I'll primarily discuss nonmedical exemptions in this post. However I will also discuss medical exemptions to give a thorough understanding of different exemption types.  Their ethical status is closely linked with mandates in that they bring the issue of personal freedom to the forefront. If an individual’s religious or other values are in opposition with vaccines, vaccine exemptions allow the choice to delay or reject vaccination. This is valid; however the question must be asked. Should there be a limit to this? Or at least; should nonmedical exemptions be more closely regulated? Why? To discuss this, it is important to note that it is not vaccine effectiveness itself that is in question. It is the relationship between nonmedical exemptions and the freedom to make medical decisions that is.


  • According to the website of the CDC; medical exemptions are allowed when a child (or presumably an adult) has a medical condition that prevents them from receiving a vaccine. Further, due to age or other factors; some people should not receive certain vaccines or wait before they are given. For instance; anyone who has had an allergic reaction following previous doses of the MMR vaccine or has serious life threatening allergies are advised by the CDC to tell their healthcare providers before vaccinating. These principles are usually understood and accepted by the general population.  However ethical difficulties can arise when such exemptions are misused. For example; 


What can be understood from this is that medical issues can usually be measured and standardised. A list of symptoms can usually be understood and accepted by the general population. However, personal and religious values cannot always be. In this case; where the boundaries of exemptions ought to be are less clear.


For this reason; it is worth discussing whether nonmedical exemptions should be regulated more strictly, or be eradicated completely. I`ll explore these questions in this blog post. 


The first thing to clarify is that many people hold sincere religious beliefs. Undoubtedly in many cases, religious beliefs are in opposition with vaccination, and possibly other healthcare procedures. Jehovah's witnesses refuse blood transfusions; for instance. The refusal will usually be maintained even if it results in their own death, or the death of a loved one. Further, in a 2019 survey, 44% of Americans – along with 45% of people across 34 nations – said that belief in God is necessary “to be moral and have good values.” The point is; religious beliefs are often sincere. They comfort people in difficult periods and reflect their value systems. By extension; religious opposition to medical products or procedures are often genuine.


Another reason individuals may decline vaccinations or other medications on religious grounds is a sense of autonomy. I`ve said this before but it is worth repeating; respecting patient autonomy is a core principle of medicine. No serious healthcare professional would ever dispute that. Making the patient a key stakeholder in decision-making is important for establishing good patient-provider relationships. It also makes patients more likely to trust the physician`s medical judgement; for current decisions and in the future. Respecting decisions based on religion or any other personal belief falls under the concept of respecting patient autonomy. With that, it can be said that in cases where there is no severe risk of harm, religious beliefs can be respected. This is the reasoning behind religious exemption systems. 


However, there`s an important phrase there that I will draw your attention to - “where there is no severe risk of harm.” In cases where there are outbreaks or epidemics of infectious disease, a risk of harm applies. In these cases; belief exemptions can be used in ways that do increase the risk of harm. It's on this basis that an argument could be made for regulating these exemptions more strictly. 


With that said; how exactly do such exemptions increase risk of harm to others? One way this happens is when exemptions are issued without proper justification. On that note, one such case is where false claims to being exempt from vaccines on religious grounds are made. Law professor Dorit Reis has accumulated both anecdotal and survey evidence that most claims to rejecting vaccines on religious grounds are false. Further, according to an article from, some pastors are more lenient than others in distributing letters that support their parishioner`s request for a religious exemption. Some pastors will even provide letters for anyone who asks. Not only this; sometimes Bible verses are quoted out of context (ie. “Jesus went around healing lepers and touched them without fear of getting leprosy/ Lord, I called to you for help, and you healed me.”; 1 Corinthians 6:19: “Do you not know that your bodies are temples of the Holy Spirit?”; and Leviticus 17:11: “For the life of a creature is in the blood.””), and used as justification for rejecting vaccines,


Why then are false exemptions so common?  Stated simply, religious exemptions are easier to get than medical exemptions. Religious views are much more subjective than medical data. For example; medical exemptions must be obtained from general practitioners, paediatricians, clinical immunologists, infectious disease, general or public health physicians, gynaecologists or obstetricians. Specialised documents are required which cannot easily be fabricated. However, in U.S states such as Indiana and Massachusetts; patients simply need to cite religious reasons to be exempt from vaccination. This may cause people to seek them out. Indeed; many U.S states do allow parents to reject vaccination for their children if their religious or philosophical beliefs contradict vaccination. 

 Further, there are hundreds of organised religions across the world. Only about 5 subsects of the Catholic church outright ban vaccination. These include a subset of Christian faiths including the Dutch reformed Church, Church of the First borne, Faith Assembly and Endtime Ministries. The more major religions like Judaism, Hinduism, Jainism, Jehovah's Witnesses, Islam, and many more don't directly oppose vaccines. Vaccination is also widely accepted in predominantly Buddhist countries. So anti-vaccine ideology is not a tenet of most organised religions.It takes only a few facts to see this.  According to the website of the Vanderbilt Faculty, Hindus venerate cows. However, it also says that trace bovine components of certain vaccines have not been identified as a theological concern. Further, the Muslim doctor Nour Akhras wrote an article entitled “As A Muslim Doctor, I Don`t Say Vaccination Is Permissible, I Say It Is Obligatory”. This leaves the remaining subjects with no standardised advice on granting vaccine exemptions. For these reasons, defining when and why religious exemptions should be granted is much more challenging.  


From this, let`s review the main question; should they be regulated more strictly? Generally, religious exemptions are reserved for those who have sincere religious reasons for opting out of vaccination. The same would apply for any medical procedure. That would be the case in an ideal world. In an ideal world; that would only be a small minority of people. It wouldn't be enough people to compromise herd immunity. However, we live in a less than ideal world where people can and do take advantage of systems like these.  Many claims to religious exemptions have been found to be false; and some religious authorities give exemption letters to their parishioners very liberally. Further, although no religion outright bans vaccination (except for several Christian subsects), the advice on exemptions varies from religion to religion. That lack of unified advice makes it even more difficult to decide where the limits of religious exemptions should lie. For all these reasons; it may be worth restricting exemptions in some cases where there is severe risk. This is especially true if there is risk to one or more vulnerable individuals such as children, the elderly, or those with specific health conditions. 

Personal belief exemptions 


Personal belief exemptions, although they can include religious views, are slightly broader than religious belief exemptions. This is because they are based on people`s broader value systems generally as opposed to just religious beliefs. According to an article published on in September 2019, “Personal belief exemptions allow parents to decline vaccinations for their child by claiming vaccination is incompatible with their personal beliefs or religion.” 


It also stated that restricting such exemptions can have a positive impact on vaccination rates. The article states that “California passed SB 277 becoming the third state to remove personal belief exemptions from the state’s mandatory vaccine schedule. In response to measles cases, many states this year have introduced bills to restrict vaccine exemptions.In 2016, the year after California removed its personal belief exemption, kindergarten vaccination rates for MMR increased from 92.9% to 95.6%.” Further, a 2019 study by Sindiso Nathi and colleagues found that, at the state level, nonmedical exemptions decreased by 2.4%, with medical exemptions increasing by 0.4%. At the county-level, overall vaccination coverage increased by 4.3%. To summarise, eliminating nonmedical childhood vaccine exemptions was linked with increased vaccination coverage and a reduction in nonmedical exemptions at both state and county levels. It is therefore clear that in some contexts, restricting exemptions can increase vaccination coverage. This can, in turn, be beneficial for public health. 


However, the question that naturally follows is; why? Why does this work? I`d argue that convenience is the most obvious reason for the majority of people. Children still need to go to school. One could counter that they could be homeschooled, if parents were adamant about not vaccinating. However, not all families have the time, energy, resources or the education to homeschool their children. Homeschooling is a significant commitment, and many parents may have concerns about being able to teach their child or children effectively. In many cases, both parents` incomes are required to provide for the family. In other cases, it may be a single-parent household meaning that homeschooling simply isn't an option. The point is that not having the option of personal belief exemptions, and with medical exemptions having such narrow criteria, vaccinating is the only remaining option. Homeschooling is a privilege not afforded to many. 

Why else might personal belief exemptions be so widespread? The second reason links with a phrase that I mentioned slightly earlier in the post - autonomy. More specifically, I`ll talk about parental autonomy in making medical decisions for their child or children. It`s a recurring theme in vaccine discussions that I've discussed before here, and for good reason. Parents devote their lives to their children, and with that invest significant time, energy and resources into ensuring their health and wellbeing. Generally, in the course of everyday life, parents are the key decision makers for their children (of course, more for younger than older children, but the idea generally applies). So in general, they know the best course of action to take for their child. They may not be accustomed to having decision making partners when it comes to their children. It is that that can make vaccine discussions very difficult. It is for that reason that some parents place huge emphasis on having input on their child's health care decisions. If they feel like they do not have any input; this may be one element of why personal belief exemptions are sought. 


So, to address the key question; should personal belief exemptions be regulated more strictly? Generally, I`d argue that patients and especially parents should be key stakeholders in their medical decision making. The idea of personal belief exemptions really boils down to the idea of personal autonomy. Lack of control and fear of the unknown are two of the most difficult things people can experience. With that said; it would be irresponsible to place others lives at risk under the guise of personal freedom, or personal belief exemptions, It's important that the physician is the primary source of medical guidance; but also that the patient is placed at the centre of the decision making. 


Knowing that, completely removing personal belief exemptions may not be the best approach. However, increasing regulation on them such that exemptions can only be given after every effort has been made to inform them of the risks of not vaccinating, queries addressed and concerns listened to. I`d argue that most of that is a given. However, the next point is not so clear. It's commonly said that if there is a “severe risk” of harm, personal belief exemptions should be overridden. However, it's important to define what exactly we mean by “severe risk.” How much risk should there be? Does someone need to be at risk of being hospitalised? Or can exemptions only be overridden when a patient has already been hospitalised? Why? Could exemptions be more easily overridden in higher-risk groups of patients, especially children? I`d also add that it is also important to standardise how we approach this regulation across different countries, groups of patients and so on. A standard approach will make it easier to make improvements to it and integrate these improvements across differing areas of practice. This in turn will allow medicine to move forward as a whole with regulating personal belief and other vaccine exemptions. Another point I`d like to make is that regulatory processes should be in accessible language. This will allow patients and any non-medical disciplines involved in regulating vaccine exemptions (ie. lawyers) to engage in discussions with a full understanding. 


To summarise, the criteria for medical exemptions are narrow; with criteria for religious and personal belief exemptions being far broader. The latter are far more subjective than the former. With that subjectivity; the specifics of why people seek nonmedical exemptions can vary hugely from person to person. Unfortunately, this can at times mean that the nonmedical exemption system is abused. On those grounds; nonmedical exemption types should be regulated. That said; patient autonomy should always be respected, especially in the case of parents making medical decisions for their children. Also, any approaches to regulating exemptions should be standardised across different areas of practice and conveyed in accessible language. Both of these approaches should allow medicine as a field to progress in this area; and also for patients and non-medical disciplines (ie. lawyers) involved in regulating exemptions to engage in discussions with a full understanding. What is key is that any approach should be based in empathy between the physician and patient. Thanks for reading. 


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  • References


  1. Exemptions from State Vaccination Requirements | CDC.
  2. Who Should not Get Vaccinated | CDC
  3. What’s the law on vaccine exemptions? A religious liberty expert explains
  4. Anti-vaxxers appear to be losing ground in the online vaccine debate
  5. Blood transfusion refusals – why new guidelines aren’t up to scratch
  6. Faith still shapes morals and values even after people are ‘done’ with religion
  7.  PolitiFact | Few religions ban vaccination, but that counts little for religious                                        exemptions

    . 8.   Immunizations and Religion | Vanderbilt Faculty & Staff Health and Wellnes

9. As   a  Muslim Doctor, I Don’t Say Vaccination Is Permissible, I Say It Is                     Obligatory - Interfaith America

10. California law to restrict medical vaccine exemptions raises thorny questions over control

11. Vaccine mandates vs. religious beliefs – the legal arguments for the upcoming coronavirus lawsuit

12. The 2016 California policy to eliminate nonmedical vaccine exemptions and changes in vaccine coverage: An empirical policy analysis - PMC CC BY 4.0 Deed | Attribution 4.0 International | Creative Commons

13. Homeschooled children are far more socially engaged than you might think