Halakha Approaches the COVID-19 Vaccine

Rachel tried to reason with the clerk at the check-in counter. She explained that she had delayed vaccinating herself and her children because she did not want to be the first to receive a new vaccine, especially one designed at “warp speed.” “We are sorry but you cannot board this flight without proof of COVID-19 vaccination. It’s the airline’s policy.” Rachel began to cry. She explained that she had not seen her parents since before the outbreak of COVID-19, almost two years earlier. She asked to speak to the supervisor, to no avail. The airline refused to allow Rachel or her children to board the flight.¹

This scene could easily represent our future reality, recurring on a daily basis in workplaces, schools, and stores once the much-anticipated COVID-19 vaccine arrives. 

As the number of cases soars, the world urgently needs an effective vaccine against the virus. Scientists and countries are collaborating to achieve this goal at record speed. However, the eventual vaccine will have a limited impact on the pandemic if people do not consent to be vaccinated. Surveys from several countries indicate that a large percentage of the population say that they will refuse a vaccine. In the United States, 65% say that they are willing to be vaccinated, while 35% would refuse. In a similar study from Long Island, among those who would agree, 14% would be “among the first,” 33% would only vaccinate after others do so, and 32% would wait for most people to be vaccinated. While most parents accept routine vaccinations for their children, only 38% would agree to a COVID-19 vaccine for them. Surveys conducted in the UK, France, and Israel report comparable rates of COVID-19 vaccine refusal. Reasons for vaccine refusal include the concern that the vaccine was developed too quickly without long-term data regarding efficacy and safety, distrust of science and authority, and conspiracy theories. 

While these surveys raise alarms regarding the effectiveness of a vaccine at halting the pandemic, they might not accurately predict true vaccination rates once one has been developed. A 1954 Gallup poll indicated that only 60% of people would accept a polio vaccine, yet when one became available, the vaccination rate soared. 

The reasons to be vaccinated are compelling and include a reduction in the risk of infection to the individual, his family, and those around him. Relying on the development of immunity through infection alone (the Swedish model for dealing with COVID-19) has been considered ineffective. Vaccination appears to be essential to herd immunity, which occurs when a large portion of a community becomes immune to a disease. If enough people are vaccinated, society will achieve herd immunity, making its spread from person to person unlikely. This protects an entire population, not just those who are immune. Although scientists disagree over the minimum threshold necessary to create COVID-19 herd immunity, they agree that there is no maximum threshold above which herd immunity cannot be improved. The more immune people, the lower the risk of infection for everyone. A decision to vaccinate promotes not only one’s own personal health and that of one’s family and loved ones, but also helps to eradicate a disease, saving millions of lives and allowing the world to end social distancing and other restrictions. Vaccination is thus both an act of altruism and a communal obligation. 

In light of the integral role that a COVID-19 vaccination will play in ending the pandemic and the possibility that many people will refuse the vaccine, it behooves us to examine how halakha approaches the matter. Would halakha permit Rachel to undergo COVID-19 vaccination, a new vaccine with limited data attesting to its long-term safety and efficacy? Does halakha obligate her to do so to protect herself and others and to help create herd immunity? Must she vaccinate her children? May governments and private institutions compel vaccination? 

Does Halakha Permit or Even Obligate COVID-19 Vaccination?

Avoda Zara (27b) permits a sick individual with limited time to live—hayyei sha’a—to risk his remaining time and receive potentially life-saving treatment from a pagan doctor, who might kill him. The Gemara explains that, “we are not concerned about a risk to a person with only a short-term life expectancy. Perhaps the doctor might cure him”; i.e., it is worth the risk. Based on this principle, halakha permits one to undergo a risky medical treatment in the hope of a long-term cure, even when the treatment carries a risk of immediate death. 

May Rachel, a healthy, young woman, receive a medical treatment for a disease that she does not and might never have? In 1785, 11 years before Edward Jenner introduced the smallpox vaccine, R. Abraham Nanzig, who had lost two children to the disease, permitted variolation.² A precursor to vaccination, this intervention involved the deliberate infection of a healthy individual with smallpox or cowpox, causing a mild form of the disease that then created immunity. Though the procedure was associated with a one in 1,000 risk of death, he dismissed this danger because the risk of death from smallpox was far greater; he considered the treatment a mitzva. R. Nanzig cited the precedent of bloodletting, which was permitted although it caused fainting, but rarely death. He cited Rif, who allowed a more primitive form of variolation in which a child who had survived smallpox was given raisins to warm in his hand. A healthy child would then eat them, experiencing a mild infection and subsequent immunity. Following Jenner’s introduction of the smallpox vaccination, Tiferet Yisrael (Boaz, Yoma 8:3) permitted a healthy individual to be vaccinated and achieve long-term immunity from the virus, despite the risk. He wrote, “It appears that one may be vaccinated against smallpox even though one in 1,000 people will die from the vaccination. The reason for this is that if one were to be struck by a natural case of smallpox the danger would be even greater, and one may subject himself to something that rarely leads to danger in order to avoid a more likely danger.” He based this ruling on Beit Yosef, Hoshen Mishpat 426, which, citing Yerushalmi Terumot, chapter 8, obligates a person to place himself in possible danger to save his friend from a certain danger. So, for example, if someone sees his friend drowning in the sea, he must jump in to save him though he risks his own life during the attempted rescue. Tiferet Yisrael notes that Rif, Rambam, and Tur do not quote Yerushalmi, perhaps because they hold like R. Yossi (Nedarim 80b) that “your life takes precedence over the life of your fellow man.” Tiferet Yisrael concluded that a healthy individual may accept possible immediate peril to save himself from a possible future danger, although he is not obligated to do so. He suggested that halakha views future danger as already present and equates disease prevention with the treatment of active disease. Virtually all modern poskim require, or at least permit, vaccination against childhood diseases.³ Can we extrapolate from these halakhic rulings to a COVID-19 vaccination?

While the virus is too new to allow us to quantify the true risk of infection, the fatality rates for COVID-19 in the United States and Israel are 3% and 0.6%, respectively (as of this writing), significantly higher than the anticipated risk from vaccination. Tiferet Yisrael permitted the smallpox vaccination because a vaccine that causes one death in 1,000 qualifies as “something that rarely causes danger.” When asked whether one need be concerned about the possibility of misdiagnosing death and burying someone who has all of the signs of death but nevertheless has a one in 10,000 risk of still being alive, Hida writes, “we are not concerned about such a remote possibility” (Hayyim Sha’al II, no. 25). R. Hershel Schachter has stated that “if the adverse reaction risk for a given vaccine was in the range of one in 1,000,000, the concept of batla da’ato eitzel kol adam would be applied to mitigate an individual’s fear, which might have prevented him from being vaccinated.”⁴ Does a COVID-19 vaccine qualify as something that rarely leads to danger? Although its safety and efficacy are still unknown, the risks, if any, should be substantially lower than the one in 1,000 risk or even the one in 10,000. It is implausible that a democratic government subject to regulatory bodies such as the FDA, the CDC, and the National Institute of Allergy and Infectious Disease (NIAID), could approve a vaccine with a risk of death as high as one in 1,000. 

The Vaccine is New

As Rachel noted, the COVID-19 vaccine will be new. Roughly 30% of Americans are reluctant to be among the first to be vaccinated and, like Rachel, prefer to wait until more data is available. May one be vaccinated against COVID-19 immediately after the vaccine’s release or does halakha require us to wait until risk data becomes available? Let us first consider the possibility that a new vaccine has the status of experimental therapy. Halakha permits participation in experimental therapy when “such therapy is approved by experts in the field; all possible theoretical and laboratory background work has been done; the therapy is not known to be unduly dangerous; and the patient consents to the therapy.”⁵ A COVID-19 vaccine with the relevant preliminary research would satisfy these criteria. Halakha would therefore permit Rachel to get a COVID-19 vaccination, even if the vaccine were described as experimental therapy. 

However, the vaccine will only become available once it has passed the stage of experimental therapy and qualifies as standard therapy; an innovation becomes the standard of care when rigorous scientific research has identified the specific criteria for and outcomes of use; the place, personnel, and society required for effective use; and the learning and certification necessary to assure appropriate standards of care. The vaccine available to Rachel, even if released under Emergency Use Authorization (EUA), pre-licensure use of a vaccine outside of a clinical trial during a public health emergency, will have completed “the relevant research” required of experimental therapy including rigorous phase III testing to establish safety, efficacy, and the target population for which it will be most effective. In the United States, a data safety monitoring board (DSMB) composed of independent experts, who remain anonymous to prevent pressure from vaccine manufacturers, government officials, and the public, protects the integrity of the trials and the safety of participants and reviews efficacy and safety data. Only when the DSMB is convinced of a vaccine’s merit will it advise manufacturers to send it to the FDA where it will undergo extensive evaluation. The FDA has released guidelines for vaccine manufacturers requiring them to wait two months after vaccination is complete before applying for an EUA, in order to ensure longer follow up regarding the vaccine’s safety and efficacy. In Western society, the vaccine will have received the approval of governmental institutions and international medical authorities.

What additional data might accrue if Rachel waits until more people have been vaccinated? Phase III trials plan to enroll up to 30,000 participants, and will have the statistical power to identify an adverse event that occurs in one in 1,000 individuals. These trials cannot detect uncommon or rare adverse events (in the range of 1 in 10,000 or 1 in 100,000), or those with delayed onset. Post-licensure monitoring of vaccine safety will identify and evaluate such adverse events. We will only know the complete safety record of the vaccine long after its administration to millions of patients. 

Despite our inability to determine a vaccine’s long-term safety upon its release, a review of 1,000 vaccine studies indicates that vaccines rarely cause side effects. Delaying COVID-19 vaccination until this post-licensure data is available will confirm that the vaccine does not cause very rare side effects with a risk to one in 10,000 or even one in one million, or long-term complications. Even if post-licensure data indicates that the COVID-19 vaccine does, if rarely, cause severe adverse effects, their anticipated incidence would be comparable to the risks associated with routine childhood immunizations, which all international medical organizations and governmental bodies endorse. Tiferet Yisrael does not address the chances of rare side effects from vaccination, suggesting that halakha dismisses such minimal risks. In addition, the benefits of vaccination in preventing COVID-19 infection and ending the pandemic are projected to outweigh the risks of potential long-term adverse events. Delaying vaccination even one day will exact a high cost in human life. Although the daily death toll from COVID-19 in the United States stands at 927, the true cost to human life of each day that the pandemic continues is immeasurable—and probably far greater than this, due to excess mortality from non-COVID-19 illness (caused by delays in medical care from fear of infection and an overburdened healthcare system), economic hardship, unemployment, and the deterioration of mental health. 

Thus, the benefits of COVID-19 vaccination, presuming positive trial outcomes, far outweigh its potential risks. From a halakhic standpoint, Rachel may subject herself to something that rarely causes danger in order to avoid a more likely danger.

COVID-19 Vaccine and Achieving Hayyei Olam – Long-Term Cure

No vaccine is 100% effective in preventing infection. The rate for most routine childhood vaccines is 85% to 95%, and for the flu vaccine, 40% to 60%. Although the efficacy of a COVID-19 vaccine is unknown, Dr. Stephen Hahn, the director of the FDA, has stated that the agency will approve a COVID-19 vaccine with an efficacy of 50% or greater. Ideally, the FDA will rely on phase III clinical data to establish this. However, it might implement “emergency use” in a specific population such as health-care workers or, perhaps, even for the general population. If the FDA does approve such an emergency release, it has stated that it will only do so if there is at least 50% efficacy.⁶ 

Does halakha permit one to risk a hayyei sha’a for a treatment that has a 50% chance of hayyei olam?⁷ Poskim offer several parameters for hayyei olam, ranging from as low as a one in 1,000 chance of cure to a greater than 50% chance.⁸ While these poskim address a situation where the individual is already ill and will certainly die shortly, Tiferet Yisrael suggests that halakha approaches disease prevention as it does active disease, and that the criteria of hayyei olam apply to the prevention of an infectious disease through vaccination. A COVID-19 vaccine with phase III data or an EUA demonstrating efficacy of 50% or greater would satisfy these poskim’s minimum requirement for hayyei sha’ah.^{9  10} However, what if the vaccine only confers short-term immunity that will diminish with time and thus does not guarantee hayyei olam? While Tiferet Yisrael might not have permitted vaccination against smallpox if the vaccine had only offered temporary immunity, other poskim allow and might even require flu vaccination, which only confers seasonal immunity.¹¹ In addition, COVID-19 booster shots could extend immunity against the virus. By the time Rachel would need a booster shot other vaccines that could confer long-term immunity might have become available. Based on this analysis, it seems that halakha would permit a COVID-19 vaccination immediately after its approval, and that there is no need to wait until long-term data is available.

Halakha might even obligate Rachel to undergo COVID-19 vaccination, as many of the principles that establish a general halakhic obligation to vaccinate might apply to a COVID-19 vaccine in particular. 

R. Shlomo Zalman Auerbach and R. Yitzchok Zilberstein suggest that public perception of danger defines safek pikuah nefesh and the consequent obligation to vaccinate.¹² With over 50% of Americans planning to get vaccinated against COVID-19, it would seem that the public perceives failure to vaccinate as a sakana for which these poskim might similarly require vaccination. For R. Elyashiv, normative behavior establishes a halakhic obligation to vaccinate. He ruled that parents must vaccinate children against whooping cough, even though the risk of complications from the vaccine had become greater than the risk of infection, since the vast majority of children were vaccinated (*)¹³ and “a legitimate government’s legislation concerning standards of medical conduct adds weight to their halakhic acceptability.” Applying this criterion to a COVID-19 vaccine, halakha might not require vaccination immediately after its release but would do so once COVID-19 vaccination becomes normal practice.  The mandate of a democratic government might hasten this obligation.

Several poskim suggest that the requirement to follow the recommendations of prevailing physicians and medical authorities obligates vaccination.¹⁴ In a joint letter, leading contemporary rabbinic authorities R. Moshe Ehrenreich, R. Yosef Carmel, R. Zalman Nechemiah Goldberg, R. Nachum Rabinovitch, and R. Yisrael Rosen write that, “if the vast majority of the physicians in the world and in Israel state unequivocally that one must vaccinate, this becomes halakha, like any halakha, and perhaps even more so because it is known that we act more stringently with dangers than with prohibitions.” They reiterate the obligation to follow the recommendation of physicians and major medical organizations. If physicians strongly recommend the COVID-19 vaccination, these poskim might rule that Rachel must get vaccinated. However, often physicians disagree over the benefits of a given treatment. What happens if some physicians and medical organizations endorse COVID-19 vaccination and others do not? R. Aviner explains that in such a situation, we follow the majority of physicians in Israel, Europe, the United States, and the World Health Organization, and we reject the minority position of dissenting physicians.

R. Hershel Schachter argues that when the government mandates vaccination, the principle of dina de-malkhuta dina obligates it.¹⁵ If a democratic government ultimately legislates that a COVID-19 vaccination is safe for the general public or specific populations, people must comply with this ruling. Jews who refuse to abide by government-mandated vaccination endanger all of society and cause hillul Hashem.¹⁶ The recent measles outbreak in Hasidic communities in the United States with low vaccination rates and the subsequent public disgust with ultra-Orthodox Jews illustrate the potential for desecrating God’s name when Jews defy normative practice and legal requirements. Thus, halakha offers many reasons for Rachel to get vaccinated, including the fact that vaccination is normal behavior endorsed by governments and medical experts.

These sources require conventional vaccination against “everyday” diseases, when there is no pandemic. Logic dictates that if this obligation exists when the risk of disease is low and the disease is dormant, it is even stronger during a pandemic. Indeed, poskim recognize the heightened urgency of vaccination during an epidemic. Rema mandates that people flee a city during a plague, specifically at the beginning of the epidemic when the prevalence of the disease is low (Rema, Y.D. 117:5). R. Asher Weiss, citing Zivhei Tzedek Yoreh De’ah (116:41) and Tokhahot Haim (Parshat Vayetze), writes that the contemporary equivalent of fleeing the city during a pandemic is vaccination.  Be’er Heitev (O.H. 576:3) writes that people who do not flee the city during a plague are liable for their own fate.”  If vaccination is the contemporary equivalent of fleeing, halakha might apply this classification to Rachel and those who decline vaccination during a pandemic. R. Herzog permits vaccination on Shabbat if physicians prescribe this during an epidemic.¹⁷ R. Mordechai Halperin has stated that an individual who refuses vaccination during an epidemic could be classified as a rotzeah be-grama—an indirect killer—or a mazik—one who causes damages—due to the pain and suffering he might cause others by transmitting a non-life threatening disease.¹⁸ In response to the recent measles epidemic, representatives of Agudath Yisrael, in conjunction with the Av Beit Din of Chicago, stated that one who fails to vaccinate in the midst of an epidemic has the halakhic status of rodef—murderer. During the pandemic, which exacts a high cost to human life every day, Rachel’s obligation to undergo COVID-19 vaccination becomes even stronger. 

The Obligation to Vaccinate to Protect Others

Halakha might require Rachel to vaccinate in order to protect not only herself from infection but also others, and for the good of the community. Sanhedrin 73a derives the obligation to save someone in danger from Leviticus 19:16, “do not stand idly by.” Sefer ha-Hinukh, mitzva 237, explains the rationale behind this obligation. “Just as someone will save his neighbor, so too, his neighbor will save him. This is how the world will be saved.” Exposing someone to an infectious disease abrogates one’s obligation to the community and the fulfillment of several mitzvot including, “all Jews are responsible for each other,” “do not stand idly by,” and “love your neighbor as yourself.” Sefer Hasidim, no. 673, prohibits someone who suffers from an infectious disease to bathe in a public bathhouse unless he informs the others of his disease, otherwise he violates, among other precepts, lifnei iver—do not place a stumbling block (Lev. 18:14). In their paper regarding vaccination, R. Carmel and his colleagues classify someone who refuses vaccination as a rodef because he puts others at risk of infection and endangers the public. An individual who fails to vaccinate creates a safek sakana de-rabim because he has the potential to infect many others. To prevent this, R. Auerbach permits the autopsy of an infant who died shortly after vaccination in order to determine whether the vaccination caused the death. Though this likelihood is remote, he nevertheless authorizes the procedure as a way to prevent even a single death and safek sakana de-rabim.¹⁹ Along these lines, all members of the community are obligated to be vaccinated in order to avoid infecting others, help achieve herd immunity,²⁰ and ensure the safety of the community, even if their personal risk of infection is low. This is “how the world will be saved” in general, and specifically from the COVID-19 pandemic.

The Obligation of Parents to Vaccinate Their Children

Is Rachel obligated to vaccinate her children? It is well established that halakha requires parents to protect the health of their children.  Shelah (Sha’ar Otiyot Derekh Eretz 13–14) extends Rema’s admonition to escape from a city early in a plague to removing one’s children from such a place, and expresses shock that parents might refuse to remove their endangered children from an epidemic-ridden town, stating that such parents will be judged for the death of their children. R. Asher Weiss obligates parents to vaccinate their children unless doing so has caused severe side effects in two older siblings. Although R. Auerbach, R. Yehoshua Neuwirth, R. J. David Bleich, and R. Schachter rule that one may not compel parents to vaccinate their children, R. Bush suggests that they would make a different determination during an epidemic.²¹ It would seem that halakha might obligate Rachel to vaccinate her children, especially in the midst of a pandemic. 

Shomer Peta’im Hashem

In a discussion regarding vaccination at the family’s Shabbat table, Rachel’s oldest son suggested that she should not vaccinate and should instead rely on shomer peta’im Hashem—the notion that “God protects the simple” (Psalms 116:6)—for protection against the virus. This halakhic principle, widely cited in the Talmud, permits behaviors that carry some level of risk if that risk is remote and society accepts it. Applying this principle to COVID-19, Rachel’s son argued that many people remain unvaccinated and nevertheless are safe from COVID-19. 

Nevertheless, shomer peta’im does not justify refusal to get a COVID-19 vaccination. Ahiezer (1:23) limits shomer peta’im to situations where the danger is only a remote possibility. With almost 30 million cases of COVID-19, the virus can hardly be considered as applying only to a remote minority. Furthermore, shomer peta’im does not apply to situations where one can eliminate the danger. R. Moshe Feinstein permitted genetic testing for Tay-Sachs. He concluded that since an intervention exists to mitigate the risk of inheriting this disease, one can no longer invoke shomer peta’im to justify refusing the treatment (Iggerot Moshe, E.H. 4:10). Similarly, shomer peta’im cannot defend accepting the danger of COVID-19 if a vaccine is available to reduce this risk. Shomer peta’im, which applies when people engage in a behavior considered dangerous, might in fact support COVID-19 vaccination despite any potential risks; since adverse effects would be relatively rare, one may rely on shomer peta’im for protection against them. R. Bleich writes, “Perfection of vaccines that immunize against disease results in a situation in which failure to vaccinate is tantamount to willfully exposing oneself to zinim pahim [thorns and snares]. Once divine providence has made a vaccine safely available, any misfortune resulting from failing to avail oneself of immunization is to be attributed to human negligence rather than to divine decree. Allowing a child to be exposed to the ravages of communicable disease is no different from exposing the child to zinim pahim. Any resultant harm is not at the hands of heaven but is derekh ikesh [a crooked path] for which the parent bears full responsibility.” 

May Schools Require Vaccination?

Does halakha permit schools to deny admission to children who have not had a COVID-19 vaccination? It is well established that halakha allows the excommunication of people who pose a public risk or endanger the lives of others (see, e.g., Rambam, Talmud Torah 6:14; Rema, H.M. 425:2).  Schools in particular pose a significant risk of infection, as many people spend significant amounts of time together there. R. Zilberstein explains that the local rabbi in charge of a school is the decision-maker in all issues relating to the school. If he determines that unvaccinated children are not following the requirements of halakha, he may deny them admission.²² Denying entry to the unvaccinated is no different than refusing admission to those who cannot pay tuition. In response to the measles outbreak, where unvaccinated individuals endangered the health of those around them, several rabbinic organizations, including Agudat Yisrael and the Rabbinical Council of Baltimore, stated that schools, playgroups, and shuls should ban unvaccinated adults or children. Thus it would seem that poskim allow private institutions, schools, and even governments to compel Rachel to vaccinate her children.

May Jews Claim Religious Exemption from the COVID-19 Vaccination?

In 1941, the United States Supreme Court stated, “The right to practice religion freely does not include liberty to expose the community… to communicable disease.” Justice Antonin Scalia reaffirmed this position 50 years later. Although several states permit religious exemptions from vaccination, such exemptions can have devastating and life-threatening consequences. Children granted religious or philosophical exemptions from the measles vaccine were 35 times more likely to contract it, posing a risk to themselves and those around them.²³ Schools with pertussis outbreaks had more children with religious exemptions than schools without outbreaks. Among already-vaccinated children, 11% developed measles through contact with a child granted religious exemption. 

Several potential COVID-19 vaccines use a human fetal kidney cell line derived from a fetus that was aborted nearly 50 years ago. Catholic leaders have raised concerns regarding these vaccines and have asked the FDA to create incentives for pharmaceutical companies to develop vaccines that do not use aborted fetal tissue. 

May Jews claim a religious exemption from the COVID-19 vaccination? In 1896, after the imprisonment of an Orthodox Jew in London for refusal to vaccinate his child, the Chief Rabbi of Great Britain testified that, “[vaccination] is in perfect consonance with the letter and spirit of Judaism.”²⁴ Regarding the claim that vaccines contain non-kosher ingredients, Ahiezer (3:61) rules that a Jew may receive nutrition containing non-kosher foods through a tube inserted into the stomach and that the prohibition against eating non-kosher food applies only to food that is swallowed. Similarly, a diabetic can use insulin containing substances derived from pigs, since it is injected and not eaten.²⁵ Thus, halakha permits medicines with forbidden ingredients in the forms of injection, suppository, enema, or medicated bandage. Regarding halakha’s approach to the use of fetal parts for medical purposes, the overwhelming majority of rabbinic authorities see no halakhic objection. In fact, giving them a potentially life-saving purpose might be preferable to discarding them.²⁶ In their respective teshuvot, R. Asher Weiss and R. Moshe Shternbuch strongly endorse vaccination and consider it pikuah nefesh, a lifesaving treatment that overrides all prohibitions except incest, murder, and idolatry. The possibility that vaccines might contain prohibited materials does not invalidate the halakhic obligation to vaccinate. R. Bush writes, “Whether a posek will rule that childhood immunizations are obligatory in halakha or are discretionary (but highly advisable), there is no position in halakha that says there is any prohibition or compelling reason to refrain from such vaccinations.” Furthermore, when a religious school that implements halakha and religious values mandates vaccination, a parent can hardly claim a religious prohibition. The Rabbinical Council of Baltimore affirmed R. Bleich’s position, declaring that, “Religious exemptions for people of the Jewish faith should not be respected.” Thus, Rachel may not claim a religious exemption from vaccinating her children.

Conclusion

Halakha permits, encourages, and likely even obligates Rachel to get a COVID-19 vaccination for herself and her children in order to protect herself and others from infection, help create herd immunity, and end the pandemic. Similarly, schools and communities should require a COVID-19 vaccination despite parents’ reluctance. We believe that failure to vaccinate violates the prohibition to stand idly by another’s blood.  

We hope that a safe and effective vaccine will be developed and disseminated in the very near future. It is our best hope to alleviate the worldwide suffering and to arrest the horrific death toll brought about by the COVID-19 pandemic. When it does arrive, we feel that it is morally obligatory and halakhically mandated that people accept the vaccine.

And so, in a final effort to clarify the airline’s policy, the director of public relations for the airline explains, “While you can decide that you are not afraid of COVID-19 infection for yourself or your children, could you live with yourself if you infected other passengers, your parents, or your grandparents? Could you live with yourself if you prolonged this pandemic?”

Sharon Galper Grossman, MD, MPh, is a radiation oncologist, former faculty member of Harvard Medical School, and a graduate of the Morot L’Halakha program at Matan Hasharon. She lectures and writes about health and halakha.

Rabbi Dr. Shamai Grossman is vice chair for health care quality, Harvard Medical Faculty Physicians, and associate professor of medicine and emergency medicine at Harvard Medical School.

[Published on October 20, 2020 – Read a July 2023 exchange of views on this essay published here.]

1. The interested reader should see our recent article “Signing Up for a COVID-19 Vaccine Trial,” The Lehrhaus (August 18, 2020), which addressed how halakha views participation in trials that enroll healthy volunteers, randomly giving half of them a COVID-19 vaccine under investigation and half a placebo, and subsequently deliberately infecting both groups with the virus. Although such trials endanger healthy individuals, they might reduce the time required to complete phase III testing and thus accelerate the approval of a vaccine. The halakhic opinions cited in the article would seem to permit but certainly not obligate participation in such a trial, because 1) a healthy individual may incur a small risk of death to achieve long-term immunity; 2) the risk of participation is comparable to the risk permitted for other acts of altruism such as kidney donation; and 3) the potential benefit to society is immeasurable. This current article addresses a separate COVID-19 topic: How halakha might approach a vaccine that has completed phase III testing and received FDA approval. Specifically, we analyze whether halakha permits or even obligates an individual to receive an approved COVID-19 vaccine that lacks long-term safety and efficacy data, whether a parent must arrange for his child to undergo COVID-19 vaccination, and whether schools may compel COVID-19 vaccination.
2.  Abraham Nanzig, Aleh Terufah (1785), 1b, 6, 12.
3. Aaron Glatt, et al., “Compelled to Inoculate: May Parents Refuse Vaccinations for Their Children?” Journal of Halachah and Contemporary Society 65 (Spring 2013), 55–72; Asher Bush, “Vaccination in Halakhah and in Practice in the Orthodox Jewish Community,” Hakirah 13 (2011), 185–212; J. David Bleich, “Survey of Recent Halakhic Periodical Literature: Vaccination,” Tradition 48:2 (2015), 41–56.
4.  J. DiPoceand S. Buchbinder, “Preventive Medicine,” Journal of Halachah and Contemporary Society 52 (Fall 2001), 99, citing personal communication, fn. 134.
5. Akiva Tatz, “Approach to Risk in Halacha,” Dangerous Disease & Dangerous Therapy in Jewish Medical Ethics (Targum Press, 2010), 204.
6. In committing to a vaccine efficacy of at least 50% the FDA has stated that it will require the lower bound of the 95% confidence interval to be greater than 30%, suggesting that statistical analysis must confirm with 95% certainty that the vaccine is at least 30% effective.
7. For additional discussion regarding the definition of hayyei olam see our recent essay in The Lehrhaus.
8. Mishnat Hakhamim (108), Hilkhot Akum, as cited in Ahiezer Y.D. II 16:6, Tzitz Eliezer 10:25:5, Iggerot Moshe Y.D. III 36 and Y.D. II 58, Hatam Sofer Y.D. 76, Beit David Y.D. II 340.
9. Philip Krause, et al., “COVID-19 Vaccine Trials Should Seek Worthwhile Efficacy,” World Health Organization Solidarity Vaccines Trial Expert Group (Lancet, August 27, 2020). A danger of administering a vaccine with an efficacy of only 50% is that, once vaccinated, people might assume that they are immune, when there is a 50% chance that they are not. This could lead them to forsake COVID-19 related precautions. To avoid this all too likely scenario, it will be important to educate the public that people are still at risk after vaccination and must continue to exercise caution at least until the end of the pandemic. However, even if the vaccine is only 50% effective, it could reduce the severity of disease, the likelihood of death, and the long-term sequelae of infection.
10. If the FDA implements an EUA and releases a vaccine with an efficacy of 30%, it would fall below the threshold of Mishnat Hakhamim and Tzitz Eliezer for hayyei olam, but be above that of Iggerot Moshe and Beit David. However, the nine companies performing phase III trials on the vaccine have stated that they will “only submit for approval or emergency use authorization after demonstrating safety and efficacy through a phase III clinical study that is designed and conducted to meet requirements of expert regulatory authorities such as FDA.” This suggests that an EUA of a COVID-19 vaccine is unlikely, and that they will only release the vaccine when phase III trials are complete.
11.  R. Yitzchok Zilberstein, “Letters: Vaccination,” Journal of Halachah and Contemporary Society 69 (Spring 2015), 96–102.
12. R. Yitzchok Zilberstein, “Letters: Vaccination.”
13. Akiva Tatz, “Approach to Risk in Halacha,” Dangerous Disease & Dangerous Therapy, 48. (A personal communication with R. Tatz on February 23, 2018, confirmed that this conversation occurred in R. Elyashiv’s home in Jerusalem.) [* An earlier version of this article mistakenly stated that R. Elyashiv ruled parents must vaccinate children against smallpox.]
14. Nishmat Avraham Hoshen Mishpat 427; Minhat Shlomo 2:29:d.
15. See n. 3, supra.
16. 16
17. Heikhal Yitzhak, O.H. 31.
18. Aaron Glatt, et al., “Compelled to Inoculate: May Parents Refuse Vaccinations for Their Children?,” Journal of Halachah and Contemporary Society 65 (Spring 2013), 55–72, 69, fn. 27.

19. Mordechai Halperin, “The Laws of Saving Lives: The Teachings of Rabbi S. Z. 

    Auerbach.” Jewish Medical Ethics 3:1 (January 1997), 44–49.

20. R. Asher Weiss accuses those who refuse to vaccinate of shirking their communal responsibility and taking a free ride at the expense of the vaccinated. He argues that halakha prohibits an individual from engaging in behavior that is harmless when a single person does it but that causes harm when many do. If only one individual refuses vaccination, society will not be at risk. But if everyone refused, the epidemic would continue and their refusal would harm all of society. Thus, while the world might achieve herd immunity even if Rachel does not get vaccinated, as an individual she might nevertheless be obligated to do so.
21. Asher Bush, “Vaccination in Halakhah and in Practice in the Orthodox Jewish Community,” Hakirah 13 (2012), 1.
22. Yitzchok Zilberstein, “Letters: Vaccination,” Journal of Halachah and Contemporary Society 69 (Spring 2015), 96–102.
23. Daniel A. Salamon, et al., “Health Consequences of Religious and Philosophical Exemptions from Immunization Laws,” JAMA 282:1 (July 7, 1999), 47–52.
24. Asher Bush, “Vaccination in Halakhah and in Practice in the Orthodox Jewish Community,” Hakirah 13:1 (2012), 186.
25. Avraham Steinberg, editor, Encyclopedia of Medicine and Jewish Law 3:271.
26. F. Rosner and E. Reichman, “Embryonic Stem Cell Research in Jewish Law,” Journal of Halachah and Contemporary Society 43 (Spring 2002), 49–69.