Despite the great advances of medical science over the past 150 years, there are still groups that reject one or more medical treatments because of their religious beliefs or cultural traditions. The largest of these are the Jehovah’s Witnesses, with nearly seventeen million active members worldwide; while the Jehovah’s Witnesses used to object to a range of medical practices, today their only objection is to blood transfusions.
Several small churches, however, advocate reliance on prayer and ritual to the exclusion of medical care in most cases of illness. Denominations that have lost children since 1980 because their religious beliefs led believers to forgo medical care for children include Followers of Christ, Faith Assembly, Church of the Firstborn, Christian Science, Faith Tabernacle, End Time Ministries, Church of God of the Union Assembly, Church of God Restoration, Twelve Tribes, Christ Miracle Healing Center, and followers of Ariel Sherman, Jon Lybarger, and Roland Robidoux.
Some parents have religious beliefs against immunizations but will seek medical treatment when their children are sick. The Worldwide Church of God, Upper Room Christian Fellowship in Indiana, and the Maharishis in Iowa have had measles outbreaks because of their religious exemptions from immunizations, but those affected sought medical treatment. Many chiropractors oppose immunizations and have joined the Universal Life Church so as to be able to claim a religious exemption from immunizations.
The Amish have low vaccination rates and in many cases have relied on folk remedies and health quackery. They have had outbreaks of polio, measles, and pertussis, and cases of tetanus among their children because of failure to immunize. However, their practices seem based more on a fondness for nineteen-thcentury culture than on theological precept.
In addition to an avoidance of immunizations, some religious belief systems call for following strict diets that may be harmful, especially to growing children and those who are sick. Furthermore, immigrants from some ethnic minority cultures have brought their own remedies to the United States and use them on sick children in lieu of Western medical care.
I. Beliefs that Cause Medical Neglect of Children
II. Beliefs against Immunizations
III. Diet and Nutrition
IV. Beliefs in Nonbiological and Spiritual Causes and Cures
V. Public Policy
VI. Constitutional Issues
Beliefs that Cause Medical Neglect of Children
The Jehovah’s Witnesses’ opposition to blood transfusions is based on Bible verses such as Genesis 9:3–6, Leviticus 17:10,11, and Acts 15:22–29 and 21:25, which require abstinence ‘‘from blood’’ and prohibit eating ‘‘meat that has its lifeblood still in it.’’ Because of Bible verses directing that blood be poured out on the ground, the Witnesses oppose the storage of blood. Witness theology holds that the soul is in the blood and that Christ offered a perfect atonement for human sin by shedding His blood. To accept a blood transfusion, according to this theology, constitutes eating blood and tramples on the sacrifice of Christ.
The Watchtower Bible and Tract Society, which makes policy for the denomination, also prohibits autotransfusions, in which the patient’s own blood is stored for later use. The Society interprets Bible verses as prohibiting the storage of blood. It prohibits transfusions of whole blood and of its four primary components: red cells, white cells, platelets, and plasma. As membership has grown into the millions, however, the Society has added many caveats to its prohibition against transfusions. An early one was an allowance for hemophiliacs to take clotting factors VIII and IX. The Society explained those as acceptable because they were only ‘‘minor’’ components of blood. Then Witnesses were allowed to accept the blood products albumin and immunoglobulin. The Society said those were acceptable because, like the clotting factors, they were fractions of blood plasma.
Additional exceptions followed. A heart-lung or kidney dialysis machine was allowed because the blood flows through the machine continuously and therefore is not removed from the body. Blood-gas analysis tests on premature infants were also allowed. The tests involve removing 1–3 milliliters of blood, withdrawing a test specimen, and returning the remainder to the infant’s bloodstream.
The Society continued to prohibit fractions derived from red cells, white cells, and platelets until 2000, when it published an anonymous statement that fractions derived from all the primary blood components were acceptable. Thus, Jehovah’s Witnesses are now able to accept interferons and interleukins from white cells, and fibrinogen (a wound healing agent) from platelets.
Witness theology still prohibits the most common kind of transfusion, packed red blood cells. Furthermore, deviant Witnesses who voluntarily accept them run the risk of being disfellowshipped and shunned by family and friends. The AIDS pandemic as well as the Witnesses’ strong opposition to transfusions have led to greatly reduced use of blood transfusions and to development of blood substitutes in medical practice. Nevertheless, many doctors consider blood transfusions necessary for certain conditions of infants and children who need immediate improvement in oxygen delivery.
Critics claim that the policy changes are given out so cursorily that members may not even understand they have occurred. They typically come in a column of questions from readers in the Society’s publication, with brief anonymous answers and no acknowledgment that the policy is being changed.
Some countries have refused to grant Jehovah’s Witnesses status as a religion because its prohibition of transfusions violates human rights agreements. Witnesses have been arrested, lost their property, and been forced to serve in the military because their faith was not recognized by the government. To gain recognition in Bulgaria, the Jehovah’s Witness leadership pledged to the government in 1998 that its Bulgarian members had freedom of choice to accept transfusions without any control or sanction from the church. Reform groups distributed news of the agreement and charged that the Witnesses had a different policy in Bulgaria than in other countries. The Watchtower Society denies there is a difference.
The Pentecostalism that began in America in the 1890s encouraged exclusive reliance on faith healing, but as Pentecostal denominations, such as the Assembly of God, grew larger and more structured, they dropped their objections to medical care. Most faith-healing groups that withhold medical care from children today are charismatic and believe that St. Paul’s ‘‘gifts of the spirit,’’ described in I Corinthians 12 and including faith healing, have been restored to them. Some, such as Faith Tabernacle, emerged within the Pentecostal revival of the 1890s, yet some Christian apologists charge that the theology of contemporary faith-healing groups is not Pentecostal, but Plotinian.
Many sects that discourage medical care express the positive confession theology of Kenneth Hagin. This movement is also known as ‘‘Name-It-and- Claim-It,’’ ‘‘Word Faith,’’ and the ‘‘Health and Wealth Gospel.’’ It teaches that the crucifixion was a vicarious atonement for both sin and disease. Christians must make ‘‘positive confessions’’ of their salvation through Jesus Christ and then the devil’s temptation or disease will leave them. The positive confession, also called ‘‘pleading the blood’’ by some sects, is a legalistic argument that the crucifixion has already saved them from disease and therefore the disease has no ‘‘right’’ to affect them. Disease symptoms are regarded as a temptation from the devil to sway believers away from their God-given rights. After the believer has made this positive confession, he or she is, according to former Faith Assembly members, expected to stand firm on it and know that his or her healing is guaranteed. Heor she should ignore disease symptoms as simply demonic temptations. This theology also encourages material prosperity. It teaches that God has promised Christians a right to material possessions, which they can get by ritually claiming them.
Critics charge that the movement teaches that God can be controlled by saying the right formulas. They also criticize it for the many preventable deaths of children that have occurred in its ranks. Several of the charismatic faith-healing sects advocate home deliveries of babies without medical attention. They believe that husbands are lords of the household and should be in control of childbirth. A former medical nurse named Carol Balizet has written books promoting what she calls ‘‘Zion Births’’ of babies that occur with no medical attention. She writes approvingly of a husband who orders his wife back into bed, though she wants to go to a hospital. She praises husbands who put their hands on their wife’s hips and belligerently order God to enlarge them so the baby can be delivered. Balizet and Reverend Hobart Freeman, among other faith healers, claim that doctors deprive husbands of their God-ordained priesthood by touching their wives and babies and seeing them unclothed.
Research published in the American Journal of Obstetrics and Gynecology indicates that the mortality rate of infants in Freeman’s Faith Assembly church was 2.7 times higher than among other Indiana infants, while the maternal death rate among Faith Assembly women was 86 times higher than that of other expectant mothers in Indiana.
The best-known church promoting exclusive reliance on spiritual means of healing is the Church of Christ, Scientist, commonly called the Christian Science church, founded by Mary Baker Eddy. This church does not have a charismatic style of worship, nor is the crucifixion central to its promises. Christian Science believes that matter and spirit are opposites. The material world is an illusion and a lie about God’s creation. Man is God’s perfect spiritual reflection, coexistent with God, never born into matter and never dying, according to Christian Science.
Christian Science theology holds that disease is caused by sin or fear and that the only effective way to heal or prevent disease is to draw closer to God. Its spiritual treatments for disease include denying that disease can exist and that a person can be tempted to believe disease is real. The theology opposes medical treatment and diagnosis for children and adults alike. It opposes not only drugs, but also hygiene, immunizations, therapeutic diets, manipulations, vitamins, and health screenings because they are ‘‘material methods’’ to evaluate, treat, or prevent disease.
Eddy did make a few exceptions in the prohibition of medical treatment, such as dental care, prescriptions for eyeglasses, and use of morphine, which she used herself. After criminal charges were filed in childbirth deaths, Eddy advised going to doctors for deliveries of babies. She also recommended that Christian Scientists have broken bones set by surgeons. The church has a rule that one cannot have Christian Science treatment while he or she voluntarily accepts medical treatment unless the medical care is for an exception approved by Eddy. Critics charge that the threat of refusing to pray for the church member frightens members away from considering medical care. The church counters that medical science and Christian Science have antithetical methods and beliefs, and, therefore, combining the two could harm the patient.
Many children have died or been permanently harmed by religion-based medical neglect. A 1998 Pediatrics study reported on 172 deaths of U.S. children whose parents withheld medical care on religious grounds between 1975 and 1995. Children died of diseases that have been routinely treated by physicians for decades. The authors of the study found that 140 fatalities were the result of conditions for which survival rates with medical care exceed 90 percent. Eighteen more had expected survival rates exceeding 50 percent, and all but 3 of the remainder would have had some benefit from medical care. In the ten years since the study was published, the authors have learned of more than 100 additional child fatalities in faith-healing sects.
Twenty-eight of the deaths in the Pediatrics study were of Christian Science children. The Christian Science church, however, claims that the mortality rate for Christian Science children is less than half that for children in the general population and that its spiritual treatments should be a legal substitute for medical care of sick children. The church’s data cannot be independently verified because the church does not disclose how many children are receiving only Christian Science treatment for illnesses, what illnesses they have had, or what the outcomes have been.
For many critics of religion-based medical practices, the issue is not only that children die, but how they die. Many have suffered for long periods of time without sedatives. Some survivors have had permanent injuries because of religion-based medical neglect in childhood. Some have lost vision, hearing, or lung capacity or been permanently crippled.
Beliefs against Immunizations
Religious opposition to vaccines is not new. In colonial times many American Puritans opposed the new inoculation against smallpox on grounds that people would be more sinful if they were not afraid of the disease. Until the 1970s the Watchtower Society claimed that blood contained all personality characteristics. It opposed vaccines because they admitted ‘‘animal matter’’ into the human bloodstream and could cause moral insanity, sexual perversions, and criminal tendencies. In 1952 the Society dropped its opposition to vaccines that did not have blood products in them.
The Christian Science church opposes immunizations because it believes that disease is caused by wrong thinking rather than by bacteria and viruses. It also believes that disease should be prevented by understanding one’s spiritual immunity as God’s perfect child.
Many of the charismatic faith-healing groups oppose immunizations because they believe that life and death are determined by the will of God. Many also believe that the crucifixion of Jesus has redeemed them from disease. Some denominations oppose injecting ‘‘foreign’’ substances into the body because they hold that the body is God’s temple. Lurid charges circulate that vaccines are made from monkey kidneys and began the AIDS pandemic. Some charge that vaccines are made from aborted fetal tissue. Tissue from fetuses aborted in Europe for therapeutic reasons was used to develop fully characterized cell strains, which are reconstituted from frozen stock to make vaccines for rabies, rubella, hepatitis A, and varicella (chickenpox). No further fetal tissues are used. The Catholic Church has not opposed vaccines.
Some fundamentalists have raised opposition to the hepatitis B vaccine, which states began requiring in the 1990s. They believe that hepatitis B is transmitted only by sexual contact and needle exchange and that their children will not have sex out of wedlock or use illegal drugs because of their Christian values. Having their children vaccinated against hepatitis B, they argue, suggests that they will be promiscuous and encourages them to be so. Hepatitis B, however, has modes of transmission other than sexual contact and needle exchange. It may be transmitted through an open skin wound or mucosal surfaces, regular household contact with a chronically infected person, or occupational exposure, particularly among health care personnel. Infants of infected mothers are at risk. The disease has been endemic in mental institutions, and deinstitutionalization has led to the placement of carriers in schools and child care centers. About 30 percent of infected persons do not show symptoms, making control difficult. The disease has a 15 to 25 percent risk of death from chronic liver disease or liver cancer.
Followers of Maharishi Mahesh Yogi have low vaccination rates. They claim that they are creating a ‘‘disease-free society’’ by reestablishing ‘‘balance between the body and its own inner intelligence through Vedic knowledge.’’ They use ‘‘the complete knowledge of Natural Law’’ in ‘‘the 40 aspects of Veda and the Vedic literature’’ that were recently discovered by a medical doctor ‘‘as the basis of the 40 aspects of human physiology,’’ the website says.
There are 152 schools in the United States, some of which are public schools, affiliated with the Waldorf Movement founded by Rudolf Steiner on the principles of Anthroposophy. Steiner also established anthroposophic medicine based on ‘‘spiritual science.’’ While its treatment centers and practitioners are mostly in Europe, there are also some in the United States. Steiner’s followers have claimed that vaccinations weaken the immune system and that allowing children to contract diseases naturally will strengthen their immune systems. In 2002, half the students at Shining Mountain Waldorf School in Boulder, Colorado, lacked some or all of the vaccinations mandated by state law. The Waldorf Movement claims the schools do not teach a religion, but simply use a pedagogy based on Anthroposophy. Critics charge that Anthroposophy is an occult religion.
Physicians point out that vaccines give adequate immunity in most cases and spare the child the risks and the pain of contracting the disease. However, the American Chiropractic Association opposes mandatory immunizations. It calls for states to grant exemptions from childhood immunizations based on the parents’ conscientious objections. In states that do not grant philosophical or conscientious exemptions from immunizations, but only religious and medical exemptions, some chiropractors join the Universal Life Church and claim a religious exemption for their children.
Chiropractic theory includes supernatural elements. D. D. Palmer, the founder of chiropractic, believed that the body has a life force separate from the brain, which he called ‘‘innate intelligence.’’ Later, he described it as a personified part of universal intelligence (God). His theory holds that spinal manipulation removes interference with the normal functioning of the innate intelligence and thereby allows the body to heal itself of all or most diseases. Like Christian Science, classic chiropractic theory simply does not believe that viruses and bacteria cause disease.
Groups with religious or philosophical exemptions from immunizations have had many outbreaks of vaccine-preventable disease. In 1972 a Christian Science boarding school in Greenwich, Connecticut, had one of the largest U.S. polio outbreaks in the post-vaccine era. Eleven children were left paralyzed. The epidemic was not discovered by health authorities until twenty days after the first student had become ill with the disease. The last U.S. cases of polio from the wild polio virus occurred in 1979 among Amish communities in Missouri, Iowa, Pennsylvania, and Wisconsin. One child died; two were permanently paralyzed.
Two Christian Science children have died of diphtheria since 1982. A California chiropractor’s child died of diphtheria in 1998. In 1997 a twelve-year-old Amish boy in Pennsylvania contracted tetanus. His medical bills were $600,000. The Amish community refused to apply for Medicaid because of their religious opposition to accepting government assistance and were able to pay only $60,000 of the bill.
In 1990 the Followers of Christ in Oregon City, Oregon, had 69 cases of rubella. In 1991 there were nine outbreaks of rubella in Amish communities in New York, Michigan, and Tennessee. More than a third of U.S. rubella cases in 1991 occurred among the Amish. In February and March, 1991, Philadelphia had 492 cases of measles and 6 deaths among children of the Faith Tabernacle Congregation and the First Century Gospel Church. Between 1985 and 1994 there have been five large-scale outbreaks of measles at the Principia schools for Christian Scientists in the St. Louis area and at a Christian Science camp in Colorado. Three young people died of complications from measles in the first of the five outbreaks. The 1994 outbreak spread to 247 children, including many outside of the Christian Science community. It is the nation’s largest measles outbreak since 1992.
Such outbreaks have also occurred in other countries where immunizations and other modern medical treatments are readily available. In 1993, five years after the last case of polio was reported in Canada, health officials found 21 cases of wild polio virus type 3 (primarily in children) among an Old Netherlands Reform Church congregation in southern Alberta. In 2000 the Netherlands had 3,000 cases of measles and 3 child deaths due to the disease. The outbreak began at a Dutch Orthodox Reformed school where most children were not vaccinated for religious reasons.
Such outbreaks are costly to society. Iowa spent $142,000 to control a measles outbreak started in 2004 by Maharishi University students. A 2005 measles outbreak among families who belong to the Upper Room Christian Fellowship cost Indiana an estimated $500,000.
Diet and Nutrition
Rigid beliefs about nutrition have caused harm to children. Babies and young children have a greater need for fat and protein than adults. Vegan diets can be dangerous for children without careful monitoring. Some parents who have endangered their children by vegan diets are deviant Seventh-Day Adventists who believe that plants are the only foods the Bible approves of. Ellen White, the founder of the Seventh-Day Adventist Church, did encourage vegetarian diets, exercise, and ‘‘natural remedies,’’ but the church does not require them, nor does it encourage avoidance of medical care. The Adventists, in fact, have licensed hospitals and medical schools.
Church of Scientology founder L. Ron Hubbard has written that babies should be fed barley water rather than breast milk. He claimed to have ‘‘called up’’ the formula for barley water ‘‘from a deep past’’ some 2,200 years ago. He claimed that it heals babies because ‘‘Roman troops marched on barley.’’
The Black Hebrew Israelites practice veganism and other customs prescribed in the Pentateuch. Some avoid medical care. Literature about the Black Hebrew Israelites does not explain why some avoid medical care or whether veganism is practiced as the way to maintain health. They believe that they are descended from a lost tribe of ancient Israel, who were expelled by the Romans, migrated to West Africa, and later reached the United States as slaves. They believe that God has a plan to purify them through suffering and then lead them back to Israel. They are not recognized as Jews by Israel’s rabbinate. Other African American groups with strict dietary rules are the Rastafarians and MOVE.
The International Natural Hygiene Society (website 2006) believes in eating only raw plant foods to cleanse the body of toxins and to maintain health. It claims that all disease is caused by ‘‘wrong behavior’’—specifically, breaking ‘‘divine laws’’ about care for the body. The cure for cancer is to ‘‘stop all toxins, return to a pristine mode of living, [and] give the body maximal rest (including mental rest)’’ (website 2006).
Rigid vegan diets have caused deaths of children as well as vitamin deficiency, rickets, anemia, anorexia, lethargy, edema, kwashiorkor, marasmus, angular cheilitis, goiter, ketonuria, methylmalonic aciduria, tremors, hypotonia, pancytopenia, neurodisability, silver toxicity, and other maladies. Particularly common is deficiency in vitamin B12, because its significant dietary sources are only foods of animal origin. Adults may do well without intake of vitamin B12 for years because of their endogenous stores of the vitamin, while infants restricted to a vegan diet may become sick within a few months.
There are several reasons that parents allow their children to deteriorate with dangerous diets. When the dietary beliefs are based on religion, parents may not evaluate the children’s conditions rationally. Also, parents believe that ‘‘natural remedies,’’ including nutrition, take longer than drugs and surgery to become fully effective. Those on the raw-foods diet are often told to interpret discomfort as part of a detoxification process.
Beliefs in Nonbiological and Spiritual Causes and Cures
Some ethnic groups, such as Hmongs who have recently immigrated to the United States, adhere to spiritual explanations for the cause of disease and want to rely on rituals to cure it. In The Spirit Catches You and You Fall Down, Anne Fadiman tells of a Hmong child in California who suffered a seizure at three months old. Her family attributed it to the slamming of the front door by an older sister. They felt that the fright had caused the baby’s soul to flee her body and become lost to a malignant spirit.
Her impoverished parents took her to Minnesota for treatment by a Hmong shaman called a txiv neeb, who tied spirit-strings around her wrist and gave her herbal potions. They purchased a cow, had it slaughtered, and put its head on their front porch to welcome the return of their daughter’s soul. They paid $1,000 for amulets for her to wear. They also brought their epileptic daughter to a medical clinic and a hospital more than a hundred times in four years. But they did not follow doctors’ orders for medications, partly because the directions were too complicated for non- English speakers and partly because they had more faith in their traditional ritual cures. The girl is now brain-dead.
With the exception of the Jehovah’s Witnesses and perhaps the Black Hebrew Israelites, these groups have in common nonbiological explanations for the cause and cure of disease. Moral, spiritual, or supernatural factors cause disease according to faith healers, natural hygienists, Maharishis, traditional Hmongs, and others. The cure, then, lies in realigning the patient with divine laws through prayer, ritual, and willful denial of evidence that does not fit the believers’ overarching theory.
The Jehovah’s Witnesses, by contrast, are not faith healers. They do not claim that God will heal them of the need for transfusions. They believe that they are following commandments in the Bible, and their literature has more than once conceded that their obedience may cost them their earthly life. The Witnesses generally seek medical care, but also want a contract from the physician that no transfusion will be used. In return, they offer to sign a statement absolving the physician of responsibility for harm. The validity of such agreements is questionable.
Largely because of lobbying by the Christian Science church, there are hundreds of state laws giving religious exemptions from child health care requirements. They are of two kinds: religious exemptions dealing with medical care for sick or injured children and religious exemptions from preventive or diagnostic measures.
The first type came into state codes primarily because of federal government coercion. In 1974, solely because of Christian Science lobbying, the federal government began a policy of requiring states to enact a religious exemption to child neglect laws. The policy was enforced through the power of funding: If states wanted federal money for child abuse and neglect prevention and treatment programs, they had to pass a religious exemption.
In 1983 the federal government dropped the policy and began requiring states in the grant program to include failure to provide medical care in their definitions of child neglect. This was partly because of child advocates’ opposition to religious exemptions and partly because the Reagan administration wanted to require medical care for handicapped infants—the Baby Doe cases.
The federal government does not ask states to remove their religious exemptions. When the federal Child Abuse Prevention and Treatment Act (CAPTA) was reauthorized in 1996, it included the statement that nothing in CAPTA ‘‘shall be construed as establishing a Federal requirement that a parent or legal guardian provide a child any medical service or treatment against the religious beliefs of the parent or legal guardian’’ (Public Law 104-235). The same federal law which requires states in the grant program to have laws requiring medical care of children allows these states to have laws letting parents withhold medical care from children on religious grounds—no matter how sick the child is.
Many organizations oppose religious exemptions from child health care laws, including the American Academy of Pediatrics, American Medical Association, Prevent Child Abuse America, National District Attorneys Association, National Association of Medical Examiners, and Children’s Healthcare Is a Legal Duty. They have achieved the repeal of or significant improvement in the exemption laws of several states. Nevertheless, thirty-nine states still have religious exemptions in their civil child abuse and neglect laws, and two more have civil code exemptions for ‘‘nonmedical remedial treatment,’’ which the Christian Science church has interpreted to include their prayers.
Religious defenses to crimes against children exist in thirty states, with twenty having religious defenses to felonies and ten to misdemeanors. Two other states have defenses against criminal charges for ‘‘nonmedical remedial’’ methods, while Florida’s religious exemption, though only in the civil code, was grounds for the Florida Supreme Court’s overturning of a criminal conviction of Christian Science parents in Hermanson v. State, 604 So.2d 775 (Fla. 1992).
The actual reach of the religious exemption laws varies widely. Some clearly give parents the right to withhold even lifesaving medical care from a child. Others just as clearly give parents only a right to pray. Most are ambiguous, and some have been interpreted by state courts in divergent ways.
Delaware has a religious defense to first-degree murder at 11 Del. Code §1103(c); Arkansas has a religious defense to capital murder at Ark. Code 5-10-101(a)(9). The Revised Code of Washington states at 91.42.005 that ‘‘[i]t is the intent of the legislature that a person who, in good faith, is furnished Christian Science treatment by a duly accredited Christian Science practitioner in lieu of medical care is not considered deprived of medically necessary health care or abandoned.’’ New Hampshire Revised Statute 639:3 allows all parents to endanger children on religious grounds: ‘‘a person who pursuant to the tenets of a recognized religion fails to conform to an otherwise existing duty of care or protection is not guilty of an offense under this section.’’
The religious defenses of some states, however, protect only a right to pray. Rhode Island General Law § 11-9-5(b) states that ‘‘a parent or guardian practicing his or her religious beliefs which differ from general community standards who does not provide specified medical treatment for a child shall not for that reason alone be considered an abusive or negligent parent or guardian; provided the provisions of this section shall not (1) exempt a parent or guardian from having committed the offense of cruelty or neglect if the child is harmed under the provisions of (a) above.’’
Most religious exemptions to civil abuse and neglect laws do not prevent courts from ordering medical care for children over the religious objections of parents. The Delaware Supreme Court, however, prohibited state child protection services from taking custody of a Christian Science toddler with cancer, in part because of the religious exemption law (see Newmark v. Williams, 588 A.2nd 1108 [Del. 1991]).
The civil religious exemptions have, however, sometimes discouraged reporting of sick children in religious objector families. When statutory definitions of neglect say that withholding medical care on religious grounds is not neglect, people may feel that cases should not be reported to state child protection services. For example, Mississippi Code § 43- 21-105(l)(i) states, ‘‘A parent who withholds medical treatment from any child who is under treatment by spiritual means alone through prayer in accordance with the tenets and practices of a recognized church or religious denomination by a duly accredited practitioner thereof shall not, for that reason alone, be considered to be neglectful under any provision of this chapter.’’ Conversely, Michigan and Florida laws state that children at risk of serious harm for lack of medical care must be reported to state child protection services even though their parents have a religious exemption from being adjudicated as negligent (Mich. Compiled Laws § 722.634 and Fla. Statutes 39.01[f], respectively).
Among preventive and diagnostic measures, religious exemptions exist from immunizations, metabolic testing, newborn hearing screening, blood lead– level tests, prophylactic eye drops, vitamin K, and bicycle helmets. Two states, Oregon and Pennsylvania, have exemptions from laws requiring that children wear helmets when riding bicycles if parents believe they should wear religious headgear instead. The Christian Science church has led the lobbying for the other types of exemptions. Nationwide, forty-eight states have religious exemptions to immunizations, and forty-six have religious exemptions from metabolic testing or allow all parents to refuse the test.
Since 1982 criminal charges have been filed in more than sixty U.S. cases of child fatalities or severe injuries when parents have withheld medical care on religious grounds. There have been convictions in forty-nine cases; convictions in six cases were later overturned on appeal: Lybarger v. People, 807 P.2d 570 (Colo. 1991); Martin v. Commonwealth, Va. Court of Appeals unpublished memorandum opinion in record #0863-90-2 (1992); Hermanson v. State, 604 So.2d 775 (Fla. 1992); Commonwealth v. Twitchell, 617 N.E.2d 609 (Mass. 1993); Hernandez v. Florida, 645 So. 2d 1112 (Fla. 1994); and Walker v. Keldgord, U.S. Dist. Ct., Eastern Dist. Calif., #CIV S-93-0616- LKK/JFM (1996). Most of the overturns were based on the parents’ constitutional right to due process and fair notice of a crime, which the courts held was violated by a statutory religious exemption. Also, trial judges have dismissed the charges in three deaths of children on due process grounds: State v. Miskimens, 490 N.E.2d 931 (Ohio 1984); State v. Miller, Mercer Cty. Common Pleas Ct., #86-CRM30; and 31 (Ohio 1986), State v. McKown, 475 N.W.2d 63 (Minn. 1991), cert. denied, 328 U.S. 833 (1992).
First Amendment guarantees of religious freedom do not give parents a constitutional right to withhold therapeutic, prophylactic, or diagnostic medical care from children. The U.S. Supreme Court has ruled that ‘‘the right to practice religion freely does not include liberty to expose the community or child to communicable disease, or the latter to ill health or death’’ (Prince v. Massachusetts, 321 U.S. 158 ). In Jacobson v. Massachusetts, 197 U.S. 11 (1905), the U.S. Supreme Court upheld a state’s right to require immunizations without exception for religious belief. The Nebraska Supreme Court upheld a state law requiring metabolic screening of infants without a religious exemption (Douglas County v. Anaya, 269 Neb. 552 ).
What remains unsettled is whether legislatures have a discretionary right to grant religious exemptions from child health care laws or whether children have a Fourteenth Amendment right to equal protection under the law and therefore the exemptions themselves are unconstitutional. Four state courts have ruled a state religious exemption law unconstitutional partially on Fourteenth Amendment grounds (see Brown v. Stone, 378 So.2d 218 [Miss. 1979]; People v. Lybarger, No. 82-CR-205 [Colo. 1982]; State v. Miskimens, supra; and State v. Miller, supra). As of this writing, the federal courts have not ruled on this issue.
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