HPV is a sexually transmitted virus that causes virtually all cancers of the cervix. Since 2006, vaccines have become available to prevent HPV infection, with rigorous scientific data confirming vaccine safety and significant reductions in precursor lesions of invasive cervical cancer. This article explores the halakhic approaches to the HPV vaccination, and weighs the evidence for and against the halakhic obligation to undergo HPV vaccination. To determine how halakha approaches HPV vaccination, the author addressed a number of halakhic questions.
- Does halakhah obligate disease prevention? Multiple Biblical sources including "ve-nishmartem me'od le-nafshoteikhem" – "And you shall protect your souls exceedingly" and "rak hishamer lekha u-shemor nafshekha" – "only guard yourself and protect your soul" establish the obligation to prevent disease. In particular, the obligation to prevent disease does not depend on a threshold level of risk.
- Does halakhah obligate vaccination in general? Contemporary poskim perceive a halakhic obligation to vaccinate against certain diseases and censure the individual who refuses vaccination for endangering the lives of others by undermining herd immunity (the phenomenon that vaccination of a significant portion of a population provides protection for individuals who have not developed immunity), increasing the risk of infection to those around him and posing a risk to society at large. The individual who refuses vaccination may have the Halakhic status of a mazzik, one who damages, or gezel – thievery. Finally, safek sakana de-rabim, concerns for the safety of the general public and larger community, may justify vaccination even when there is a minimal risk of infection.
- Does the overwhelming endorsement of the HPV vaccine by the international medical community create a halakhic obligation to vaccinate?
This endorsement and the principle that we must follow normative medical recommendations create a Halachic obligation to undergo HPV vaccination.
- Does communal responsibility to maximize herd immunity also establish an obligation to vaccinate against HPV? Does the communal responsibility to maximize herd immunity, protect public health, and prevent sakana de-rabim, obligate the public to vaccinate against HPV?
- Is the halakhic obligation to undergo HPV vaccination attenuated or nullified by
- The halakhic principle "Shomer Peta'im Ha-Shem" – God protects the simple", the justification for engaging in potentially risky behaviors. Shomer Peta'im cannot be invoked to justify withholding HPV vaccination because this principle only applies to (a) a risk which society has accepted, (b) risk which cannot be eliminated, or (c) risk associated with the performance of a mitzvah or livelihood. In fact, society has refused to accept the risk of HPV infection; the risk of infection can be eliminated with vaccination; and the risk of infection is not associated with the performance of a mitzvah or livelihood.
- PAP smear screening programs to diagnose cervical cancer. Halakhah opts for "the best medical treatment," and therefore favors HPV vaccine because PAP smear alone represents substandard treatment, while primary prevention with a vaccine is "better medical treatment" than secondary prevention with PAP smear. Additionally, PAP smear demands lifetime screening and follow up procedures for which compliance is often poor while HPV requires two injections.
- The low incidence of cervical cancer among Jews in general and in Israel in particular. Critics of HPV vaccine argue that the risk of death from HPV infection among Jews is too low to mandate vaccination applying Rabbi Akiva Eiger's requirement of a 1 in 1000 risk of death to justify chillul shabbat as a threshold level of risk to justify vaccination. Applying Rabbi Akiva Eiger's principle of 1 in 1000 risk of death to justify HPV vaccination is flawed, because Rabbi Akiva Eiger was quantifying risk to transgress Shabbat, not to justify medical intervention which does not transgress halakha. In addition, this threshold applies only to the individual, not to the general public where negligible risks even smaller than 1 in 1000 may justify HPV vaccination to prevent infection and an epidemic. The obligation to prevent disease exists even if a minority of people is at risk.
- The lack of promiscuity among religious Jews. This argument is based on the assumption that religious Jews are not diagnosed with cervical cancer. To address this issue, the author contacted the Israel Ministry of Health and Israel Cancer Association to determine the incidence of cervical cancer or HPV infection among observant Jews in Israel. Neither government body records data according to level of religious observance, so it is impossible to estimate the rates of cervical cancer or HPV infection in this population. In the absence of such data, the author searched for information regarding the prevalence of sexually transmitted diseases in the religious community as a surrogate measure for HPV infection in this population and found a single study which reported substantial rates of chlamydia infection among pregnant ultra-Orthodox women. Given the presence of chlamydia infection in the most ultra-orthodox neighborhood of Israel, it is impossible to define a religious population at zero risk of HPV infection, arguing for vaccination of all religious women until such data becomes available. In addition, promiscuity exists in the religious world. The author interviewed several professionals who work in the field and attest to several cases of potential HPV exposure from a variety of promiscuous behaviors in the religious community. Data regarding sexual behavior of religiously observant youth attending yeshiva high schools and ulpanot in Israel confirm that promiscuity exists in the religious community and that Orthodox Jews are at risk for HPV infection. The presence of HPV infection in the absence of promiscuous behavior, and the reality that sexually transmitted diseases and promiscuity exist in the religious community strengthen the halakhic obligation to vaccinate against HPV.
- Does the risk-benefit profile justify vaccination? The vaccine is considered safe with a favorable risk benefit profile such that several international medical organizations and most OECD countries recommend vaccination. Based on current medical literature, there is no halakhic question regarding risk.
- Do the social and moral implications of HPV vaccination nullify the halakhic obligation to vaccinate?
- Is there a halakhic obligation to vaccinate a sinner? Halakha holds that the sick person must be treated even if he sinned, and the obligation to heal is independent of the patient's moral character and behavior. However, two Talmudic passages ("halitehu la-rasha ve-yamut" – Feed it to the wicked man and let him die, and the lack of an obligation to save a mumar le-hachis) question the halakhic obligation to treat sinners. Invoking these passages to argue against a halakhic obligation to undergo HPV vaccination is erroneous. First of all, not everyone who is infected with HPV actually engaged in licentious behavior. For example, women who vigilantly observe the laws of niddah can contract the virus from an unfaithful or ba'al teshuvah husband who was sexually active prior to marriage and becoming religiously observant. In this and other scenarios, the infected individual did not choose to sin, HPV infection is not the result of the immoral behavior of the infected person and there is no justification for omitting treatment or preventing disease. Secondly, Halakha distinguishes between a mumar le-hachis who is not to be helped but hindered, while the mumar le-te'avon who occasionally sins out of lust or appetite should be protected and carefully treated. Those infected with HPV who did engage in sin would be classified as mumar le-te'avon whom we are obligated to save. Failure to save the habitual sinner or deliberately withholding the HPV vaccine to punish him for his sins violates "lo ta'amod al dam re'ekha"- "do not stand idly by your neighbor's blood."
- Does the possibility that HPV vaccination will increase promiscuity negate the halakhic obligation to vaccinate? Critics of the vaccine erroneously argue that any action which legitimizes or enables promiscuity even if it will lead to pikuah nefesh is prohibited. First of all, as stated previously, not all HPV infection is due to sin. Arguing that it is better to let a few sinners die than confuse the educational message to thousands of students by vaccinating does not justify withholding the vaccine from someone who has not sinned. We have an obligation to protect such a woman from infection. Secondly, there is no need to explain to children who undergo vaccination that they are receiving a shot to prevent a sexually transmitted disease and that vaccination reduces the risks of promiscuity. A brief explanation that the vaccine prevents cancer in adulthood is sufficient. Thirdly, vaccination does not actively encourage religious students to sin. Fourthly, data from the Center for Disease Control (CDC) indicate that HPV vaccination does not increase promiscuity dispelling this argument against vaccination.
- Does vaccination me-saye'a le-ovrei aveirah – aid and abet sin? Critics of the vaccine suggest that fear of HPV deters girls from promiscuous behavior, and mistakenly conclude that vaccination which removes this deterrent violates the prohibition against siyu'a le-ovrei aveirah, aiding and abetting sin. Fear of HPV infection is in fact a weak deterrent to promiscuity as vaccination only reduces the risk of HPV infection and does not prevent pregnancy, HIV or sexually transmitted diseases, which remain strong deterrents to promiscuity. Furthermore, HPV vaccination fails to meet halakhic criteria for aiding and abetting in sin since there is no guarantee that vaccinated individuals will sin, a defining criteria for me-saye'a le-ovrei aveirah.
- Should we be concerned about implications for schools that offer the vaccine? Concerns regarding a school's image do not override pikuah nefesh. Additionally, if all schools administer the vaccine, no individual school would be singled out. Furthermore, if HPV vaccine is given in conjunction with other routine immunizations, there is even less need to elaborate on how HPV is contracted.
- How do modern poskim view HPV vaccination? While some halakhic authorities do prohibit HPV vaccine, a growing number including Machon Puah and Nishmat permit it and even endorse it to prevent cervical cancer. With time, the already-documented benefits of HPV vaccine will translate into substantial reductions in the incidence of invasive cervical cancer and cervical cancer mortality. These findings will only strengthen the halakhic obligation to undergo HPV vaccine.
1. לעלוי נשמת הגאון הרב ירחמיאל בן הרב יעקב אריה גרוסמן Who dedicated his life to Torah, עם ישראל and ארץ ישראל and championed women's Torah learning
*This is a brief summary of the article "Resolving the Debate Over Human Papilloma Virus (HPV) Vaccination for Cancer Prevention in the Religious World," accepted for publication in Tradition and will appear in full pending publication.