News & Views: Two COVID-19 Vaccine “Hot Topics” — Religious Exemptions and Self-consent for Minors

The COVID-19 pandemic has stressed many systems, uncovering limitations that many had not appreciated or maybe would not have even guessed. Supply chain disruptions, staffing shortages, healthcare system limitations and more have left us feeling “worse for the wear.” Legal systems are also being tested, particularly as COVID-19 vaccines — and mandates — roll out. Recently, some of the most versed legal and ethical scholars when it comes to vaccines put pen to paper to help us understand gray areas that are being questioned or tested, so we wanted to bring them to your attention.

Religious exemptions

As the use of COVID-19 vaccine mandates has increased, so too have the discussions related to exemptions. For those who wish to avoid the COVID-19 vaccine, finding an acceptable way around the mandates has become a top priority. For some, this has literally meant quitting their jobs, but others, wanting to keep their jobs, have turned to exemptions. As medical exemptions are few for COVID-19 vaccines and personal-belief exemptions are not typically being accepted, people have turned to religious exemptions. Indeed, the use of fetal cells in making some COVID-19 vaccines has added to the convenience of citing religious beliefs as the reason for not getting the COVID-19 vaccine.

Fetal cells and science

The manufacture of adenovirus-based COVID-19 vaccines employs the use of fetal cells because, as previously described, the adenovirus has been rendered incapable of replicating and the cell line being used was adapted to supply the necessary genes for replication, and, therefore, production of vaccine virus. However, some are also shunning the mRNA vaccines because fetal cells were used to produce large quantities of the spike protein for early experiments that determined how to stabilize its three-dimensional (3D) structure. Because the mRNA COVID-19 vaccines deliver genetic material, and not proteins, they do not require the use of this technique or cell line to be produced.

Also, as an aside, misinformation suggesting that influenza vaccines are made using fetal cells has also been spreading this fall. To be clear, production of influenza vaccines does not require the use of fetal cells. Most are grown in eggs, and the two types that are grown in cells (FluCelVax^® and Flublok^®) employ canine kidney cells and insect cells, respectively.

Fetal cells and religion

While some have called for vaccine manufacturers to abstain from using fetal cells, no major religions have suggested that their followers forgo COVID-19 vaccination. Indeed, while the Catholic church has expressed a preference for followers to receive the mRNA-based COVID-19 vaccines, they indicated that if necessary, followers can get an adenovirus-based version in light of the situation, citing “the morality of vaccination depends not only on the duty to protect one's own health, but also on the duty to pursue the common good.”

In light of the number of people exercising religious exemptions, Dorit Reiss, a professor of law at University of California Hastings, penned an interesting article in The Washington Post discussing the deceitful nature of some claims for religious exemptions. In the perspective piece, Professor Reiss discussed the history of religious freedom in the U.S., some recent cases related to religion and how they may signal changes in the position of the Courts on religious freedom. Professor Reiss also described the different burdens on institutions and private employers in this area of the law, adding additional context related to the support of vaccinations by churches as well as the unique situation of a pandemic. In concluding, Professor Reiss outlined four approaches that states and employers can take:

1. Offer religious exemptions and don’t police them
2. Don’t offer religious exemptions and anticipate being sued
3. Offer religious exemptions and police them
4. Offer a “personal” exemption that is not specific to an individual’s religious ideology

The considerations for each of these options are presented.

Read the complete commentary, “People lie about their ‘religious’ objections to vaccines. Proving it is hard.”

See related resources:

• Religious concerns, Immunization Action Coalition (IAC)
• Vaccine ingredients – fetal cells, Vaccine Education Center (VEC)

Child consent to vaccination

In early summer 2021, social media in the Philadelphia area was abuzz. It turns out a group of teen ambassadors promoting COVID-19 vaccinations among their peers had created a flyer advertising an upcoming vaccination clinic and included a mention that teens did not need parental consent to get the COVID-19 vaccine. Their flyer was accurate in that Philadelphia had a law in place since 2007 allowing unaccompanied teens between 11 and 18 years of age to consent for their own vaccinations. In May 2021, COVID-19 vaccines approved under emergency use authorization (EUA) were added. However, outside of Philadelphia County, teens were not given this same authority. Indeed, Pennsylvania, like many other states, does not allow teens to consent to vaccinations on their own.

Recently, Nina Shevzov-Zebrun and Arthur Caplan penned a commentary published in Vaccine in which they offered a brief legal background on teen consent, considerations for allowing teens this authority (from both the point of view of the minor and the parent), the options that policymakers have in designing related bills, and considerations for medical providers.

The three categories of policy options described included:

1. “Blind” allowance, meaning that age is the only requirement for the authority of teens to make their own decisions about COVID-19 vaccination
2. Subjective allowance, meaning expanding upon existing bills based on “mature minor doctrines” that may or may not include age
3. Alignment with privileged healthcare services, meaning defining COVID-19 vaccination in a category of care that qualifies teens to make their own decisions

In describing considerations for medical providers and noting the slow pace of policy-level changes, the authors discussed things providers can do to protect their patients in the absence of legal authority, such as providing trusted resources, addressing parental fears, reinforcing the necessity of vaccines generally, and discussing each patient in the context of their own “unique medical and social circumstances.”

Read the complete commentary, “Parental consent for vaccination of minors against COVID-19.”

See related resources:

• COVID-19 Vaccination of Minors Without Parental Consent, Respecting Emerging Autonomy and Advancing Public Health, JAMA Pediatrics, July 2021
• Vaccination over Parental Objection — Should Adolescents Be Allowed to Consent to Receiving Vaccines, New England Journal of Medicine, July 2019
• Vaxteen.org, a website by teens for teens, which includes laws for each state