Understanding Vaccine Hesitancy and Refusal Through a Rights-Based Framework

Medical liberty can be thought of as the patient’s “right to choose their preferred treatments without government interference” or “freedom of therapeutic choice.”¹ As Colgrove and Samuel explore in their article “Freedom, Rights, and Vaccine Refusal: The History of an Idea” in this issue of AJPH (p. 234) medical liberty has shaped the American response to public health initiatives throughout the centuries, including diphtheria and smallpox vaccinations. Colgrove and Samuel are right to highlight the importance of medical liberty in American healthcare thinking, especially when it comes to vaccines. Medical liberty is a core tenet that ties the Anti-Vaccination League of America and the Anti-Vaccination Society of America of the late 19th century to current antivaccination groups on Facebook and state attempts to ban mask mandates.

Colgrove and Samuel focus on the period between the 1880s and 1920s as a formative period for American vaccine resistance. But their exploration of medical liberty, including rights and freedom-based arguments, can be applied to other significant vaccination conflicts, especially regarding childhood vaccines. Applying Colgrove and Samuel’s analysis to the childhood vaccination debate can help us better understand the sources of vaccine resistance and how to better design public health responses.

Until the advent of coronavirus disease 2019 (COVID-19) vaccine mandates, opposition to school-based vaccination requirements was perhaps the foremost expression of vaccine resistance in modern life. Usually, the opposition to pediatric vaccines is presented as parental concerns regarding childhood development. In some regards, medical questions are a very present but ever-evolving concern for vaccine-hesitant parents.² The 1970s and 1980s saw a rise of antivaccination parental advocacy in the United States and the United Kingdom, spurred by a potential link between pertussis vaccination and neurologic disorders.³ More recently, Andrew Wakefield’s now debunked work suggested a link between the measles-mumps-rubella vaccine and autism.^4,5 In each case, however, concerns lingered long after it was made clear scientifically that these concerns were unfounded.^3,6

The controversy over school-based vaccination requirements can also be analyzed using the rights-based framework articulated in Colgrove and Samuel’s work, giving us better insight into the durability of vaccine hesitancy even after specific medical concerns are allayed. In 1922, the Supreme Court established, in Zucht v. King, that conditioning access to education on vaccine compliance did not violate the Fourteenth Amendment.⁷ Rosalyn Zucht, the plaintiff, relied on a rights-based framing to justify her opposition to the vaccine mandate in question, arguing that it violated her liberty without affording her due process to contest the vaccination requirements. Justice Brandeis, writing for the Court, clearly did not find Rosalyn Zucht’s rights-based argument compelling, noting that the constitutional question presented by Zucht was “not substantial in character” and was largely resolved by previous cases such as Jacobson v. Massachusetts.⁸ This is in keeping with Colgrove and Samuel’s analysis that Jacobson largely foreclosed legal remedies to compulsory vaccination.

The story of resistance to school-based vaccine mandates continued to follow Colgrove and Samuel’s framework, with advocates turning away from courts to legislation and political advocacy, all while invoking medical liberty and a rights-based framework. The medical liberty arguments documented by Colgrove and Samuel appear time and time again in parental antivaccine advocacy. A 1969 survey of school-based vaccine mandates noted that one of the two major objections to these regulations was “based on a person’s philosophy about governmental control and individual freedom.”⁹ Decades later, in a taxonomy of antivaccine advocates post-Wakefield, Anna Kirkland noted that a radical antivaccine underpinning comes from what she terms the “libertarian health freedom movement,” which includes a political theory of government illegitimacy in all healthcare matters.⁶ Many of the advocacy groups she studied, such as the Citizens’ Council for Health Freedom (an advocacy group of nonphysicians) and the American College of Physicians and Surgeons (an ideologically right-wing group of private physicians that is now more commonly known as the Association of American Physicians and Surgeons), can be seen as the political and philosophical heirs to groups discussed by Colgrove and Samuel, such as the Anti-Vaccination League of America.

The medical liberty approach to vaccine requirements goes beyond advocacy meetings, finding its way into relevant public health legislation. Following Zucht, antivaccine advocates pushed for exemptions to school-based vaccine mandates based on religious and philosophical objections. The availability of these exemptions waxes and wanes.¹⁰ In 2014, 20 states offered some sort of philosophical exemption and 48 offered some religious exemption.¹¹ In 2021, 15 states offered a philosophical exemption and 44 offered a religious exemption.¹²

Understanding the motivations behind these exemptions is important for promoting public health and vaccine adoption. Their availability can be problematic from a public health point of view, with communities falling below herd immunity when the number of exemptions granted grows too large.¹¹ These exemptions suggest that reducing parent vaccine resistance to concerns regarding neurologic development would be an oversimplification because these exceptions do little to address medical qualms. Instead, the exceptions to school-based vaccine requirements should be seen as the legislative expression of the pursuit of medical liberty.

The role that medical liberty plays in establishing exemptions to school-based vaccine requirements suggests that successful vaccine promotion must engage with libertarian health freedom arguments, not just debunk questionable scientific claims. That is to say, it is not sufficient to prove that vaccines do not cause autism. Vaccine proponents must also convince parents and policymakers “on the fence” that medical liberty does not justify undermining public health campaigns. It will not be easy to find arguments that can successfully counter medical liberty narratives, but it will be necessary for vaccine advocates to do so.

For example, to counter narratives of medical liberty, vaccine advocates may want to stress the risks posed to vulnerable individuals, such as infants and those who medically cannot receive vaccines, when communities overall fall below herd immunity. By presenting narratives and pictures of the “victims” of vaccine hesitancy—for example, a young baby with whooping cough or the story of a woman who miscarried because of measles—vaccine refusal and hesitancy could be reframed as a selfish choice instead of a “freedom-loving” choice. This approach would not reach those who are staunchly opposed to vaccines, but it may convince the vaccine hesitant to rebalance community public health goals in relation to medical liberty. More work should be done to find narratives and arguments that directly counter medical liberty–based objections to vaccines.

The lessons articulated by Colgrove and Samuel can help us better understand the opposition to school-based vaccine mandates, including explaining why religious and philosophical exemptions are so prevalent despite undermining public health goals. Colgrove and Samuel’s work reminds us that medical liberty is not a natural law as unavoidable as the pull of gravity but a choice, sometimes intentional, championed by previous antivaccine advocates after their court-focused appeals were unsuccessful. Looking forward, this framework could also be useful in addressing objections to COVID-19 vaccine requirements. As Colgrove and Samuel note, “[t]he conceptualization of vaccine refusal as a matter of rights and liberties may be consequential for efforts to control the COVID pandemic.” Pushing back on the rhetoric of medical liberty may ultimately be necessary to ensure high rates of COVID-19 vaccination, and Colgrove and Samuel’s work gives us the tools to do so.