ReligiousExemptions

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Association of Schools of Public Health

Religious and Philosophical Exemptions from Vaccination Requirements and Lessons Learnedfrom Conscientious Objectors from ConscriptionAuthor(s): Daniel A. Salmon and Andrew W. SiegelSource: Public Health Reports (1974-), Vol. 116, No. 4 (Jul. - Aug., 2001), pp. 289-295Published by: Association of Schools of Public HealthStable URL: http://www.jstor.org/stable/4598655Accessed: 22/06/2009 16:15

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PRACTICE ARTICLES

Religious a n d Philosophical Exemptionsf r o m Vaccination Requirements a n d

Lessons Learned f r o m Conscientious

Objectors f r o m Conscription

DANIEL A. SALMON, MPHaSYNOPSISANDREW W. SIEGEL, JD, PH1ab All jurisdictions in the US require proof of vaccination for school entrance. Moststates permit non-medical exemptions. Public health officials must balance therights of individuals to choose whether or not to vaccinate their children withthe individual and societal risks associated with choosing not to vaccinate (i.e.,claiming an exemption). To assist the public health community in optimallyreaching this balance, this analysis examines the constitutional basis of non-medical exemptions and examines policies governing conscientious objectionto conscription as a possible model.

The jurisprudence that the US Supreme Court has developed in cases in whichreligious beliefs conflict with public or state interests suggests that mandatoryimmunization against dangerous diseases does not violate the First Amend-ment right to free exercise of religion. Accordingly, states do not have aconstitutional obligation to enact religious exemptions.

Applying the model of conscientious objectors to conscription suggests that ifstates choose to offer nonmedical exemptions, they may be able to optimallybalance individual freedoms with public good by considering the sincerity ofbeliefs and requiring parents considering exemptions to attend individualeducational counseling.

aDepartment of Health Policy and Management, Johns Hopkins School of Hygiene and Pubic Health, Baltimore MD

bBioethics Institute, Johns Hopkins School of Hygiene and Pubic Health, Baltimore MD

The authors thank the following people for their contributions to this manuscript: Robert T. Chen, MD, MS, for the original idea ofconsidering conscientious objectors as a model for immunization exemptions and for his insightful critique of the manuscript; Eugene J.Gangarosa, MD, MS, Alan Hinman, MD, MPH, David Nailin, MD, Beth Hibbs, RN, MPH, Ruth Poh, PhD, and Jon Vernick, JD, MPH, fortheir very helpful comments; and Rachel Woods, MPH, and Beth Hibbs for providing unpublished data.

Address correspondence to: Daniel A. Salmon, MPH, Johns Hopkins School of Hygiene and Public Health, 615 N. Wolfe St., Ste. 5515,Baltimore, MD 21205; tel. 410-502-2695; fax 410-502-6733; e-mail .

?2001 Association of Schools of Public Health

PUBLIC HEALTH REPORTS / JULY-AUGUST 2001 / VOLUME 116 O 289


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290 O PRACTICE ARTICLES

Immunizations are among the most cost-effective andsuccessful of all public health interventions. Becauseof the high contagion, morbidity, and mortality associ-ated with most vaccine-preventable diseases (VPDs);the frequency of VPD transmission in school settings;and the safety, effectiveness, and potential financialsavings offered by vaccines; all jurisdictions in theUnited States have introduced and actively enforcelaws that require proof of immunization for schoolentrance.",2 Many of the laws were written with specificreference to smallpox and were later amended to in-clude other VPDs.'

Although no federal laws mandate immunization,the US Supreme Court has upheld the constitutional-ity of state vaccination laws. In 1905, the Court ruledin favor of a Massachusetts law; in 1922, the Courtspecifically addressed vaccination as a prerequisite forschool attendance.4 These federal rulings have servedas precedents for state court rulings. State immuniza-tion laws permit certain exemptions: All states allowmedical exemptions (e.g., for people who are immuno-compromised, those who have allergic reactions tovaccine constituents, and those who have moderate orsevere illness); 48 states offer religious exemptions,and 17 states offer philosophical or personal exemp-tions.3 The distinction between religious and philo-sophical/personal exemptions varies from state to state,depending primarily on the manner in which the laws

are implemented and enforced.4 In many states theprocess of claiming a nonmedical exemption requiresless effort than fulfilling the immunization require-ments, and often there is no contact between the par-ent and health personnel. The reasons that parentsforgo vaccination altogether have not been well ex-plored, but the ease of obtaining an exemption hasbeen quantitatively associated with the frequency ofexemptions.6

Data from Colorado suggest that the rate of exemp-tions is increasing.5 Between 1987 and 1998, the per-centage of personal exemptions among school-aged

children in Colorado increased from 1.25% to 2.05%(p < 0.001). Although the percentage of medical ex-emptions remained unchanged at 0.12% and relig-ious exemptions decreased from 0.23% to 0.19%(p < 0.001), the rate of philosophical exemptions in-creased from 1.02% to 1.87% (p < 0.001). Nationally, a1999 survey of state and territorial immunization pro-gram managers found that 11 programs (18%) re-ported an increase in the number of persons claimingexemptions, and only one program (1.6%) reported adecrease in the number of people claiming exemp-tions (personal communication: Beth Hibbs, RN, MPH,

National Immunization Program, Centers for DiseaseControl and Prevention; August 2000).

The health consequences of claiming religious andphilosophical exemptions have recently been explored.A study of measles in the late 1980s and early 1990sfound that children (5 tol9 years old) for whom reli-gious and philosophical exemptions had been claimedwere at greater risk (relative risk [RR] = 35) of con-tracting the disease than vaccinated children. In thesame study, mathematical modeling suggested thatthose exempted represent a risk to the non-exemptpopulation.6

Another study of measles and pertussis occurring inColorado between 1987 and 1998 found exemptors tobe 22 times more likely than vaccinated children toacquire measles and 5.9 times more likely to acquirepertussis. The same study found the rate of exemp-tions in a given county to be associated with the inci-dence rate of measles (RR = 1.6) and pertussis (RR =1.9) in vaccinated children; further, schools with per-tussis outbreaks had more exemptors (4.7% students)than schools without outbreaks (1.3% students,p < 0.001). At least 11% of vaccinated children inmeasles outbreaks were infected through contact withan exemptor. An international study of pertussis foundthat changes in public perception and policy towardvaccination led to decreases in pertussis immuniza-tion, resulting in a major resurgence in disease inci-

dence in many developed countries.7Public health officials at state and local levels, who

are responsible for maintaining and implementing stateimmunization laws, must balance the rights of indi-viduals to choose whether or not to vaccinate theirchildren against the individual and societal risks asso-ciated with choosing not to vaccinate (i.e., claiming anexemption). The aforementioned studies assist in quan-tifying the health risks of not vaccinating, but they donot address how to balance these risks with individualfreedoms concerning vaccination choice. In 1999, leg-islation was introduced and debated in at least eight

states to ease state vaccination laws or to add a philo-sophical exemption if one did not already exist. Onestate, Arizona, passed legislation permitting philosophi-cal exemptions (personal communication: RachelWoods, MPH, National Immunization Program, Cen-ters for Disease Control and Prevention; August 2000).In 1997, the National Vaccine Advisory Committee(NVAC), which advises the Assistant Secretary forHealth and the Director of the National Vaccine Pro-gram Office on immunization policy, formed a workinggroup to examine the issue of philosophical exemp-tions. The NVAC Philosophical Exemption Working

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RELIGIOUS AND PHILOSOPHICAL EXEMPTIONS FROM VACCINATION REQUIREMENTS O 291

Group issued a report that summarized existing dataand reflected a variety of viewpoints on the issue, butthe group did not make specific recommendationsregarding states permitting nonmedical exemptions.8Thus, states continue to be confronted with these is-sues without policy recommendations from the fed-eral government or its advisory committees.

To assist the public health community and thoseresponsible for maintaining and implementing stateimmunization laws in reaching an optimal balancebetween individual rights and public health risk, thisanalysis examines the constitutional basis of religiousand philosophical exemptions from state laws and con-siders issues pertaining to conscientious objectors fromconscription as a possible model.

THE CONSTITUTIONALITY OFRELIGIOUS-BASED EXEMPTIONS

It is well established as a matter of constitutional lawthat police powers authorize states to compel vaccina-tion in the interest of public health.9'10 However, theUS Supreme Court has never ruled on the constitu-tionality of religious exemptions from vaccination re-quirements. There are two central constitutional ques-tions: (a) Does the First Amendment right to freeexercise of religion require states to provide religiousexemptions from vaccination? (b) Do states have the

constitutional authority to enact religious exemptionsfrom compulsory vaccination?

The Court has developed jurisprudence in caseswhere religious beliefs conflict with public or stateinterests; the Court rulings suggest that mandatoryimmunization against dangerous diseases does not vio-late the First Amendment right to free exercise ofreligion. In a recent case the Court stated, "We havenever held that an individual's religious beliefs excusehim from compliance with an otherwise valid lawprohibiting conduct that the State is free to regu-late."'" The Court held that a law does not interfere

with the right to free exercise of religion as long as itis religion-neutral and generally applicable. The Courtspecifically weighted the balance in favor of publichealth concerns where they were in conflict with reli-gious beliefs, and the Court further underscored theimportance of protecting children from the poten-tially harmful consequences of parental decisions basedon those beliefs: "The right to practice religion freelydoes not include the liberty to expose the communityor the child to communicable disease or the latter toill health or death .... Parents may be free to becomemartyrs themselves. But it does not follow that they are

free in identical circumstances, to make martyrs oftheir children before they have reached the age of fulland legal discretion when they can make that choicefor themselves."12

A number of state courts have applied this reason-ing in holding that mandatory vaccination of schoolchildren does not interfere with the right to religiousfreedom. As the Arkansas Supreme Court noted inone such instance, "In cases too numerous to men-tion, it has been held, in effect, that a person's right toexhibit religious freedom ceases where it overlaps andtransgresses the rights of others."13

Although it is widely agreed that states do not havea constitutional obligation to enact religious exemp-tions, it is somewhat less settled whether states havethe constitutional authority to enact such exemptionsin the context of mandatory vaccination. The Missis-sippi Supreme Court has held that religious exemp-tions to compulsory vaccination violate equal protec-tion of the laws under the Fourteenth Amendmentinasmuch as the exemptions "require the great bodyof school children to be vaccinated and at the sametime expose them to the hazard of associating in schoolwith children exempted ... who had not been immu-nized as required by the statute."14 Mississippi is one oftwo states that do not permit nonmedical exemptions.

Even if it is assumed-as it generally is-that statespossess the constitutional authority to enact religious

exemptions from vaccination, there remains an issueconcerning what limitations a legislature can place onthe scope of such exemptions. There is some disagree-ment among courts concerning whether exemptionstied to membership in a recognized or establishedreligious organization violate the First Amendmentprohibition against laws "respecting an establishmentof religion." Some courts have upheld exemptions forthe children of parents with "sincere religious beliefs"but found the requirement for parental membershipin an established or recognized religious organizationto entail preferential treatment for certain religious

views and thus to stand in violation of the Establish-ment Clause of the First Amendment.'5 Other courtshave held that such requirements are compatible withthe Establishment Clause."6

The issue of the limits of a state's constitutionalauthority to enact religious exemptions will not beresolved until the US Supreme Court addresses it. Forthe time being, individual states have the de factopower to decide the matter for themselves. We do notoffer a view on whether it is constitutionally (or mor-ally) appropriate to provide for religious exemptionsfrom vaccination; however, we do believe that it is



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important to identify some principles to guide theapplication of these exemptions where they exist. Theidentification of such principles can usefully be in-formed by the considerable legislative and judicialthought that has been given to mandatory militaryconscription and the permissibility of conscientiousobjector status.

In general, there are many commonalties betweenconscientious objectors from conscription and non-medical exemptions from vaccination. To protect thenational interests from external threats, Congress hasat times (legislatively) required a portion of the publicto bear arms and fight an external enemy. Likewise, tofight the war on infectious diseases, states legislativelyrequire their citizens to be vaccinated. These duties(to bear arms and to be vaccinated) are generally

considered a potential obligation that goes hand inhand with enjoying the benefits of citizenry. With thispotential obligation come associated individual risksand individual and societal benefits. Furthermore,because the individual risks associated with both wars(e.g., battle injuries and vaccine injuries) are real butunpredictable, society has found general mandates inthe form of the draft for conscription and school en-try laws for immunization to be the most equitable wayto share these risks. To accommodate the beliefs of asmall minority of people who have strong personalconviction against war (or vaccination), states legisla-

tively permit certain persons to be exempted frommilitary duties (or immunization). Those exemptedenjoy societal benefits resulting from others who serveactive duty (who get immunized), and yet they do notshare the associated risks. Another small group is ex-empt from military service or vaccination for medicalreasons.

Of course, there are qualitative differences betweenconscription and vaccination. The magnitude of riskassociated with vaccination pales in comparison to therisk associated with conscription, and the benefits ofvaccination are substantially individual as well as soci-

etal. In comparison, the benefits of conscription areprimarily societal. Thus, assessment of individual risksand benefits associated with vaccination generally fa-vors vaccination, whereas assessment of the risks andbenefits to the individual may not favor conscription.In addition, adults incur the risks associated with con-scription, whereas children incur the risks associatedwith vaccination, and the expressed beliefs being con-sidered for exemptions are those of parents, not chil-dren. Moreover, successful immunization campaignsrequire very high levels of participation (vaccinationcoverage) for optimal success, whereas conscriptionentails enlisting the number of people needed to fill

the rolls of conscription (which could require univer-sal participation, as in some countries, although thishas not happened in the US to date). People who havestrongly held beliefs against armed conflict are likelynot good candidates for military service; in contrast,the beliefs of individual parents regarding vaccinationdo not alter their children's candidacy for vaccination.

Notwithstanding the differences between conscrip-tion and vaccination issues, the many similarities andconsiderable legislative and judicial thought investedin the issue of conscientious objectors make this modelparticularly useful in a consideration of efforts by thestate to balance individual freedoms with societal in-terests in enforcing mandatory vaccination. Moreover,the public is apt to recognize the similarities betweenimmunization exemptions and conscientious objec-

tors from conscription.'7

CONSCIENTIOUS OBJECTORSFROM CONSCRIPTION

Conscientious objector status has been an issue associ-ated with conscription in America since the Revolu-tionary War, as illustrated in a letter written by thecommander of the Revolutionary Armies, GeorgeWashington: "As ... the principal object of the enemyis . . . the City of Philadelphia, it is absolutely neces-sary, that every person able to bear arms (except such

as are conscientiously scrupulous against in every case),should give their personal service."'8

Congress has included a conscientious objector ex-emption for military service since 1864.19 Congressionalenactment of conscientious objector status has specificconditions: individuals must meet the burden of proofby establishing that they (a) are conscientiously op-posed to war in any form; (b) this opposition is basedon religious training; and (c) the objection is sincere.20Once people claiming such status have fulfilled thesethree conditions, the government must prove an over-whelming need to draft such individuals. One defini-

tion of "overwhelming need," in this context, is thatthe government must have a compelling interest inuniversal enforcement of the regulation.'4 It is gener-ally agreed that the US government has never met thisburden of proof.2'

The US Supreme Court has directly addressed thequestion of the conditions under which conscientiousobjections to war are grounded in "religious belief." Inits most recent ruling on the issue, the Court held thatfederal legislation that excludes those with "essentiallypolitical, sociological, or philosophical views or a merelypersonal moral code" from exemption applies to "thosewhose beliefs are not deeply held and those whose



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objection to war does not rest at all upon moral, ethi-cal, or religious principle but instead rests solely uponconsiderations of policy, pragmatism, or expediency."22Thus, a sincere objection based on "moral, ethical, orreligious beliefs about what is right or wrong" wouldbe allowed because it falls within the Court's defini-tion of "religion."

The Court's finding is, however, controversial. Inhis concurring opinion, Justice John M. Harlan statesthat the Court ";performed a lobotomy and completelytransformed the statute by reading out of it any dis-tinction between religiously acquired beliefs and thosederiving from 'essentially political, sociological, orphilosophical views or a merely personal moral code."'Harlan nonetheless concurs in the Court's ruling be-cause he holds that it is unconstitutional to permitexemptions for religious reasons only: "However, hav-ing chosen to exempt, it (Congress) cannot draw theline between theistic or nontheistic religious beliefson the one hand and secular beliefs on the other. Anysuch distinctions are not, in my view, compatible withthe Establishment Clause of the First Amendment."'2'Thus, even if we reject that philosophically based be-liefs count as religious beliefs, permitting religious butnot philosophical exemptions may be unconstitutional.

POLICY CONSIDERATIONS RAISED BYCONSCIENTIOUS OBJECTORS

Legislative and judicial decisions regarding conscien-tious objectors offer a useful model for consideringissues related to mandatory vaccination and nonmedi-cal exemptions and the fair allocation of burdens andbenefits. The burden of proof as established by Con-gress for conscientious objectors has not been univer-sally or comprehensively applied to exemptors frommandatory immunization requirements. Immunizationexemptions are granted through the state legislature.Doctors verify the sincerity of medical exemptions byproviding needed documentation. Some states allow

only religious exemptions and require applicants toprovide a letter from a religious leader who explicitlystates that immunizations are contrary to that religion'sdoctrine. This is a partial application of the burden ofproof for individuals claiming exemption. However,other states require no substantiation of beliefs. Forexample, in California a clause printed on the back ofthe immunization form raises the question of whetherimmunizations are contrary to the "personal beliefs"of the individual to be immunized (or more appropri-ately, to the parents). Signing this clause qualifies asan exemption, but no burden of proof has been re-quired. In such a case, the parent, by signing, may

simply be pursuing the path of least resistance. It iscertainly easier to sign your name than to make anappointment with a doctor or at a clinic, arrange totake a child to the clinic, and spend time (and per-haps money) to have a child immunized.

It is particularly difficult to address sincerity of be-liefs: How does one prove sincerity? One approachthat can be considered is the willingness of an indi-vidual to overcome barriers to achieving the goal (ofclaiming an exemption). If the process is very simple,as is in some states, anyone with even the slightestdesire to claim an exemption can easily do so. Con-versely, if the state demands more proof of sincerityfor claiming an exemption, those whose beliefs arenot as strong may decide not to pursue an exemption.What would have been the frequency of conscientiousobjectors from conscription had the Selective Servicegranted conscientious objector status as easily as Cali-fornia grants immunization exemptions?

The Supreme Court expansion of conscientiousobjector status to include people with strongly heldphilosophical beliefs poses some difficult issues forimmunization exemptions. In principle, scrutinizingthe sincerity of a parent's beliefs based on a perhapsarbitrary boundary (religion vs. philosophy) may notbe just and risks public backlash. Moreover, as JusticeHarlan argued, such a boundary may fail to be neutraland thus violate the Establishment Clause of the First

Amendment. Yet, expansion of philosophical exemp-tions could easily lead to more exemptions and, con-sequently, greater risk of disease.10 If states are ableto expand the definition of nonmedical exemptionsto include philosophically based beliefs, and at thesame time ensure a system that requires individualswho are applying for exemptions to meet carefullyconstructed criteria demonstrating strong sincerity ofbelief, it may be possible that the expanded definitionwill have little or no effect on the overall number ofexemptions. This approach, if successful in changingthe criteria for permitting exemptions without affect-

ing the frequency of exemption, would have zero ef-fect on total disease incidence but would assist in fairand equitable allocation of exemptions. This approachpresents a very fine line for legislators to walk; yet itmay offer state legislatures a strategy in addressingthese difficult and often controversial issues.

Another approach that states can consider is torequire parents who are seeking philosophical or reli-gious exemptions for their children to attend indi-vidual educational counseling prov-.Je(l by a nurse orhealth educator. In this way the pare Lts can be madeaware of vaccine issues and be told of the individualand societal risks of not vaccinating. This approach



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will ensure that parents understand the health conse-quences of the choice they are considering, resultingin better informed parents able to make meaningfulchoices that take into account not only their children'sbest interests but the interests of society as well. Theproposed counseling process would also ensure rigorand uniformity in administering nonmedical exemp-tions, features that often are lacking in the currentprocess.6 Such a process would also make it less likelythat a parent would make the exemption choice sim-ply because it is easier, and could ensure that theexemption process not be perfunctory, as it often isnow.

Whereas the state (historically) likely could not meetthe burden of proof demonstrating overwhelming needfor universal enforcement of conscription, this maynot be the case for universal enforcement of immuni-zation requirements. If the state maintains a zero tol-erance for societal risk due to exemptions, the statecould likely demonstrate the need for universal appli-cation of mandatory vaccination. In addition, diseaseeradication efforts may constitute a situation requir-ing universal coverage of vaccination, as illustrated bythe fact that the last significant outbreaks of polio inthe US occurred in religiously exempt communities(although elimination of polio was achieved in the USwithout compelling complete immunization of thesegroups). Conversely, the present success of the US

immunization program in reaching record low ratesof most VPDs, and the relatively small frequency ofexemptions, suggest that universal coverage may notbe necessary. The question is: How much societal riskis required to prove the need for universal applica-tion? Policies on exemptions from conscription donot assist us in understanding this issue because thestate has never tried to demonstrate overwhelmingneed for universal application.

It is critical to recognize the importance of flexibil-ity in the state administration of immunization ex-emptions. All school immunization requirements are

state-based; there are no federal laws mandating vacci-nation. As indicated by a representative of the Associa-tion of State and Territorial Health Officers, "varia-tions in state laws reflect differing constituencies andpolitical cultures among the states, and decisions re-garding the balance of individual vs. state rights arebest left at the state level."i" State autonomy is critical.The strategies proposed in our analysis preserve con-siderable flexibility in state implementation of immu-nization exemptions.

These policy considerations are consistent with avail-able data. A recent study by Rota and associates foundthat states that easily permitted exemptions had sig-

nificantly more exemptions than states that made theprocess more difficult.6 Furthermore, this study foundthat about half of the states that did not offer philo-sophical exemptions never denied an exemption re-quest. These states are de facto permitting philosophi-cal exemptions. States and localities may find thatcarefully monitoring and evaluating the process bywhich exemptions are granted, rather than focusingon the basis for granting exemptions (religious vs.philosophical), may more fairly balance the rights ofindividuals with the protection of the community fromVPDs. Additionally, the Rota study found that onlynine states (19%) reported having a written policy toinform parents requesting an exemption of the risksof not immunizing. This is clearly a missed opportu-nity for vaccine risk communication.

CONCLUSIONS

This review of legal issues pertaining to non-medicalexemptions from mandatory immunization require-ments indicates that states do not have a constitu-tional obligation to offer individuals exemptions. Ifstates choose to offer nonmedical exemptions in aneffort to accommodate the beliefs of a small minorityof parents, they may be able to successfully balanceindividual freedoms with the public good by consider-ing the sincerity of beliefs, rather than the source of

such beliefs, and by requiring parents considering ex-emptions to prove the sincerity of beliefs, includingattending individual educational counseling providedby a nurse or health educator knowledgeable of vac-cine issues.

Immunization programs in the US are at a criticalthreshold: their success has never been more appar-ent, yet that very success endangers appreciation bythe public. As we are now experiencing all-time lowrates of most VPDs, reported post-vaccination adverseevents, whether or not causally linked to vaccination,outnumber cases of most VPDs. Under these condi-tions, public attention can easily shift from preventingdisease to vaccine safety. This change in focus can leadto complacency on the part of parents and potentiallyincrease the number of exemptions. History tells usthat such a shift can result in resurgence of diseaseand needless morbidity and mortality.9"0

REFERENCES

1. Plotkin SA, Orenstein WA, editors. Vaccines. 3rd ed.Philadelphia: WB Saunders; 1999.

2. Orenstein WA, Hinman AR. The immunization systemin the United States: the role of school immunizationlaws. Vaccine 1999;17(Suppl 3) :S19-S24.



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3. Jackson CL. State laws on compulsory immunization inthe United States. Public Health Rep 1969;84:787-95.

4. RotaJS, Salmon DA, Rodewald LE, Chen RT, Hibbs BF,Gangarosa EJ. Process for obtaining nonmedical ex-

emptions to state immunization laws. AmJ Public Health2000;91 :645-8.

5. Feikin DR, Lezotte DC, Hamman RF, Salmon DA,Chen RT, Hoffman RE. Individual and community risksof measles and pertussis associated with personal ex-emptions to immunization. JAMA 2000;284:3145-50.

6. Salmon DA, Haber M, Gangarosa EJ, Phillips L, et al.Health consequences of religious and philosophicalexemptions from immunization laws: individual andsocietal risk of measles. JAMA 1999;282:47-53.

7. Gangarosa EJ, Galazka A, Wolfe CR, Phillips LM,Gangarosa RE, Miller E, Chen RT. Impact of the anti-vaccine movement on pertussis control: the untold story.

Lancet 1998;351:356-61.8. National Vaccine Advisory Committee. Report of theNVAC Working Group on Philosophical Exemptions.In: Minutes of the National Vaccine Advisory Commit-tee: January 13, 1998. Atlanta (GA): National VaccineProgram Office; 1998. p. 1-5.

9. Jacobson v. Commonwealth of Massachusetts, 197 US11 (1905)

10. Zucht v. King, 260 US 174 (1922).

11. Employment Division v. Smith, 494 US 872 (1990).12. Prince v. Commonwealth of Massachusetts, 321 US 158

(1944).13. Cude v. State, 237 Ark. 927 (1964).

14. Brown v. Stone, 376 So.2d 218 (Sup. Ct. Mississippi,1979).

15. Cf., Sherr v. Northport-East Northport Union FreeSchool District, 672 F.Supp. 81 (E.D.N.Y 1994).

16. Kleid v. Board of Education, 406 F. Supp. 902 (W.D.,Ken., 1976).

17. Schwaneberg R. Parental veto urged for hepatitis vac-cine. Star-Ledger 2000 May 26; p. 33.

18. Brown FL, Kohn SM, Michael D. Conscientious objec-tion: a constitutional right. New Engl L Rev 1985/1986:545.

19. Davis SE. Constitutional right or legislative grace? thestatus of conscientious objection exemptions. Fl St UL

Rev 1991:191.20. Seng MP. Conscientious objection: will the United Statesaccommodate those who reject violence as a means ofdispute. Seton Hall L Rev 1992:121.

21. Landskroener, PM. Not the smallest grain of incense:free exercise and conscientious objection to the draftregistration. Val U L Rev 1991:455.

22. Welsh v. United States, 398 US 333 (1970).


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