Introduction
For some sects, medicine and faith are incompatible. A study in Pediatrics reported on 172 U.S. children who died between 1975 and 1995 after medical care was withheld on religious grounds. It found that 140 (80%) of the children would have had at least a 90% likelihood of survival with medical care.
Christian Science is the best-known religion promoting exclusive reliance on prayer for healing. It teaches that matter and spirit are opposites. The material world and its concomitant sin, sickness, poverty, war, and death are just illusions. Man is God’s perfect spiritual mirror image, never born into matter and never dying. Christian Science holds that disease is caused by sin, fear, or ignorance of God and that the only effective way to heal or prevent disease is to draw closer to God. Its prayer “treatments” argue that God did not make disease and therefore the disease is unreal, that the “patient” is perfect and cannot be tempted to believe he has a mortal body vulnerable to disease and death.
The theology opposes medical treatment and diagnosis for both children and adults. It opposes not only drugs, but also hygiene, immunizations, health-promoting diets, chiropractic practice, vitamins, medical diagnoses, and health screenings because they are “material methods” to evaluate, treat, or prevent disease. The church prohibits its healers from giving spiritual treatments to anyone who voluntarily obtains medical care unless the care is for a handful of very specific exceptions that the church founder rationalized as acceptable. ,
Several small charismatic sects also oppose medical care. Many are grounded in “positive confession theology,” which is also known as “Name It and Claim It,” the “Health and Wealth Gospel,” and “Word Faith.” It teaches that Jesus Christ’s crucifixion was a vicarious atonement for disease as well as sin, and both are temptations from the devil. Christians must make “positive confessions” of their salvation through Jesus Christ and then the disease will disappear. The positive confession, also called “pleading the blood” by some sects, is a legalistic argument that the crucifixion has already saved them from disease. After the member makes this confession, he or she should firmly know that healing is guaranteed and ignore disease symptoms. 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.
Several of the charismatic faith-healing sects advocate home delivery of babies. They charge that doctors strip husbands of their God-ordained priesthood. Carol Balizet, a former medical nurse, has written books promoting “Zion Births” of babies without medical attention. She praises a husband who orders his wife back into bed, although she wants to go to a hospital, and husbands who put their hands on their wives’ hips and belligerently order God to enlarge them so the baby can be delivered.
Many ethnic and cultural groups believe that disease has a supernatural cause and that ritual can heal it. Many have relied on shamans to enter the spirit world through trance and mediate the sick person and their community with it. They see disease as caused by imbalances among man, nature, and spirit, and by loss of spiritual power. A folk belief among the Hmongs is that disease is caused by angry spirits or by the soul leaving the body.
All of these Christian and non-Christian groups believe that disease is caused by moral or spiritual factors rather than physiological and biochemical ones and is healed by ritual. For Christians, prayer for physical healing becomes a legalistic argument of affirmation and denial.
The Church of Scientology opposes some forms of medical care, but claims a biochemical basis for its beliefs, which is mixed with the science fiction written by its founder, L. Ron Hubbard. Scientology attacks psychiatry with vitriol. The church claims to heal all mental health problems with its “dianetics” performed in expensive sessions by “auditors” who uncover the patient’s “engrams” that are blocking health and wholeness. Then the auditors help the people to erase their “reactive mind” and reach “a state of clear.”
Scientologists believe babies should have a “silent birth” and not be exposed to any discomfort or language for the first week of life. Words or discomfort, they believe, will be recorded by the “reptilian brain” (another term for the reactive mind). Later when one experiences the same sensory data or words, his or her reptilian brain will reenact the newborn’s trauma. Hubbard claims total silence during birth is necessary to save the “sanity” of mother and baby. On that basis, Scientologists refuse to have metabolic testing, immunizations, or any other injections or testing of babies until they are 1 week old. Their dietary beliefs have endangered babies. Hubbard discourages breastfeeding because there are few “Guernsey-type mothers” today and recommends infants are fed “barley water” instead. Hubbard claims he “called up” the formula for barley water “from a deep past” some 2200 years ago when “Roman troops marched on barley.” He calls it, “… the nearest approach to human milk that can be assembled easily.”
Jehovah’s Witnesses are the largest denomination that stridently opposes a form of medical care. Their opposition to blood transfusions is based on Bible verses requiring abstinence “from blood” and eating meat with “lifeblood” still in it. Witness theology holds that the soul is in the blood and that Christ offered a perfect atonement for sin by shedding His blood. Accepting a blood transfusion constitutes eating blood and trampling on the sacrifice of Christ. The Watchtower Bible and Tract Society, which makes policy for the denomination, prohibits transfusions of whole blood and of what they claim are its four primary components: red blood cells, white blood cells, platelets, and plasma. Because of Bible verses directing that blood be poured out on the ground, the Society prohibits storing blood for autotransfusions. As membership has grown into the millions, however, the Society has allowed several exceptions to its prohibitions 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 plasma. Then Witnesses were allowed to accept albumin and immunoglobulin because they too were just “fractions” of plasma and because these antibodies can pass through the placental barrier from mother to child—therefore, receiving them is a natural bodily process. The Society continued to prohibit fractions derived from red blood cells, white blood cells, and platelets until 2000 when it published an anonymous statement that fractions derived from all the primary blood components were acceptable. That allows Witnesses to accept interferons and interleukins from white blood cells and fibrinogen from platelets.
Blood gas analysis tests on premature infants are also allowed even though they, like autotransfusion, involve taking blood from the body and later putting it back. Witness theology, however, still prohibits the most common kind of transfusion: packed red blood cells. Jehovah’s Witnesses are not faith healers. Their literature does not say that God will heal them of a need for a transfusion. Members try to persuade doctors to use blood substitutes, but if those cannot be used effectively, many claim they would rather die than accept a transfusion.
Another type of religious objection is to immunizations. Hundreds of thousands of U.S. parents refuse to immunize their children on religious or “philosophical” grounds. Often their refusal is actually based on a fear that the measles, mumps, and rubella vaccine causes autism, but their state requires them to have a religious objection to vaccines in order to get their child exempted. Some religious objectors claim that the human body is a sacred temple that should not have foreign substances injected into it. Anthroposophy, an occult sect promoted at Waldorf schools in several countries, believes that children should not be vaccinated because they will have stronger immune systems if they contract infectious diseases naturally.
Some conservative Catholics refuse consent for immunizations developed with aborted fetal tissue, including those for rabies, hepatitis A, varicella, and rubella. Catholic leaders, however, have encouraged members to obtain those vaccines if there is not an alternative type of a vaccine available against those diseases. Some fundamentalist Catholic and Protestant groups charge that the hepatitis B and the new human papilloma virus vaccines encourage promiscuity and denigrate the morals they are teaching their children. Finally, the faith-healing sects believe that one should trust God instead of vaccinations to prevent disease. Christian Science founder Mary Baker Eddy claimed that viruses and bacteria do not cause disease. Her church still teaches that parents should protect children from disease not by immunizations but rather by daily “metaphysical work” to know that God is the only cause and therefore disease is unreal.
Scores of vaccine-preventable disease outbreaks have occurred in groups with religious beliefs against immunizations. The largest U.S. outbreak of measles since 1992 began with a student at a Christian Science school. These outbreaks are very expensive to control. Often public health departments must track exposed people through several states and even countries.
The American Academy of Pediatrics and others have suggestions for providers on how to communicate with parents who have religious objections to immunizations and other medical treatment. ,
Public Policy
With a salaried lobbyist in every state, the Christian Science church has nearly single-handedly won hundreds of religious exemptions from medical care for children. Preventive and screening measures from which many state laws provide religious exemptions include immunizations, metabolic testing, blood lead-level tests, newborn hearing screens, prophylactic eye drops at birth to prevent infections, vitamin K injections or drops, vision examinations, dental examinations, and any other health screenings. The church also works to exempt Christian Science children from having to learn about disease in school.
Two states, Oregon and Pennsylvania, have religious exemptions from bicycle helmets for children. They were reportedly requested by the Sikhs.
The Jehovah’s Witnesses rarely lobby legislatures. On grounds that they are actually citizens of a heavenly kingdom, the faith discourages members from holding public office or even voting. They do, however, vigorously defend their interests in court. They have won the right at the U.S. Supreme Court to proselytize door-to-door, to refuse military service, and to refuse to salute the flag or say the pledge of allegiance. ,
The High Court ruled against them in the child labor case Prince v. Massachusetts , with its famous words 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. …” The case has often been cited in other rulings limiting religious freedom when a child’s welfare is at stake.
Scope of Laws
The religious exemptions about medical care of sick and injured children vary widely in meaning. Several states have a religious exemption in their reporting laws or in statutory definitions of child abuse and neglect. Thirty-three states have religious defenses in their criminal codes, 19 for felony crimes against children and 14 for misdemeanors. Some of these laws are chilling in their implications. West Virginia plainly says that the statute defining the crime of murder of a child “… shall not apply to any parent … who fails or refuses … to supply a child … with necessary medical care” on religious grounds. Arkansas has a religious defense to capital murder for those who cause deaths of children “under circumstances manifesting extreme indifference to human life.” By contrast, Rhode Island has a religious defense to a felony that “… does not exempt a parent or guardian from having committed the offense of cruelty or neglect if the child is harmed.” Rhode Island parents have the right to rely exclusively on prayer for healing only if the child is not harmed by the lack of medical care.
Criminal charges have been successfully pursued in several of the 33 states with religious defenses by filing charges for crimes without a religious defense or by arguing that the parent was not entitled to use the defense. , Since 1988, the U.S. Supreme Court has twice refused to review convictions of parents who withheld lifesaving medical treatment from children on religious grounds, , which suggests, although not conclusively, that the High Court regards the constitutional issues as already settled. Courts have also upheld the state’s right to require immunizations and metabolic screening without a religious exemption. ,
No U.S. court has held that parents have a constitutional right to abuse or neglect children. What remains unsettled, however, is whether legislatures may give parents a statutory right to withhold necessary medical care on religious grounds. A law that allows some parents to deprive their children of medical care while requiring other parents to provide it would seem to violate the constitutional rights of children to the “equal protection of the laws.” Four state courts have ruled religious exemption laws unconstitutional on that basis, but only one of those rulings was at an appellate level and resulted in the voiding of an exemption statute. Many organizations have called for repeal of these religious exemptions, including the American Medical Association, American Academy of Pediatrics, Prevent Child Abuse America, National District Attorneys Association, National Association of Medical Examiners, and Children’s Healthcare Is a Legal Duty.
Issues with Adolescents
Several states give teenagers the right to consent to specific forms of medical care, such as mental health and substance abuse treatment and, most commonly, sexual health care, without their parents’ permission or knowledge. Some writers argue that such laws represent an evolving concept of an adolescent’s maturity and should be extended to a right to refuse any medical treatment. They want to give adolescents the free exercise, autonomy, and privacy rights that an adult has to practice his religious beliefs and control his own body. ,
Minors with religious objections to medical treatment fall into at least three categories. Many minor children in faith-healing sects are not brought to medical attention when they are ill. Neither they nor their parents make decisions with the benefit of a medical diagnosis. They do not know the physical consequences of refusing medical treatment nor the treatment options medical science has available for their illness. The children may be very devout and have a strong faith that they should rely only on God to heal them, but they certainly do not make informed decisions. There are also children such as Starchild Abraham Cherrix in Virginia. He has Hodgkin’s lymphoma. He completed the prescribed course of chemotherapy, but within 2 months the cancer was found again, and doctors prescribed another series of chemotherapy treatments. He refused to have more chemotherapy. He and his parents voiced nondenominational religious beliefs that a special diet would be curative. The courts allowed him to forego chemotherapy temporarily and instead have radiation and nutritional therapy from a board-certified radiation therapist and report his physical condition to the court every 3 months.
Finally, there are Jehovah’s Witness children who are strongly coached to refuse blood transfusions. The Witnesses argue that they are not refusing medical treatment, but rather that they want the best medical treatment available without blood. They also argue—to providers and courts anyway—that their acceptance of most medical treatment shows that they desire to live and are not seeking martyrdom. Their internal communications, however, lavish strong praise on children who choose everlasting life in an earthly paradise over mortal life by refusing transfusions. The front cover of the May 22, 1994 issue of their magazine Awake has photos of 26 Witness children who died after refusing blood transfusions. The captions is, “Youth Who Put God First.”
Since they are under medical care, the Jehovah’s Witness children have a medical diagnosis, information about the dangers of refusing transfusions, and information about the probable success of medical treatment with transfusions. Some argue that 14- to 17-year-old Witness children should be considered “mature minors” and allowed to refuse transfusions, even at the cost of their lives.
All state child protection statutes define a child as a person under 18 years of age and allow state intervention to protect unemancipated minors until their 18th birthday. Scores of court rulings have ordered medical treatment for adolescents over their and their parents’ religious objections.
The “mature minor doctrine” is said to be evolving through case law (also called common law). Some trial courts have allowed teenagers to refuse lifesaving medical treatment. Their reasoning is unknown because opinions are sealed in juvenile cases. However, one finds only two U.S. appellate–level cases that allow minors to refuse necessary medical treatment on the basis of their maturity, and even then maturity must be balanced against other factors. The first is In re E.G. (Illinois 1989). The youth was only a few months away from her 18th birthday and had acute nonlymphatic leukemia with only a 20% to 25% likelihood of 5-year survival. The appeals court gave her the right to refuse transfusions on religious freedom grounds. The Illinois Supreme Court, however, did not uphold a constitutional religious freedom right, but instead created a common law right for minors to refuse medical care if a trial court has clear and convincing evidence that the minor is “… mature enough to exercise the judgment of an adult” and to “… appreciate the consequences of her actions” and then balances the minor’s right to autonomy against the state’s strong interest in preserving life and special duty to protect minors, the interests of parents and other relatives, and the integrity of the medical profession, which is charged with preserving life. The Court did not rule on whether E.G. was in fact a mature minor.
Oddly, the Court held that protecting the interests of parents and other third parties was more important than the state’s interests. If E.G.’s parents had opposed her refusal of blood transfusions, “… this opposition would weigh heavily against the minor’s right to refuse,” the Court said. The ruling, therefore, can hardly be seen as giving minors autonomy. It is also revealing that the Court supported its holding with reference to criminal law allowing minors to be tried as adults, an analogy that does not show a benevolent concern for teens’ welfare.
The second case also involved a 17-year-old Jehovah’s Witness. A hospital sought an order for a transfusion should it become necessary for treating a lacerated spleen. A trial judge granted the order. The girl was discharged without needing a transfusion, but the parents appealed. The Massachusetts Court of Appeals ruled that the trial judge should have considered the teen’s maturity, among several other factors, in determining her best interests and should have taken testimony directly from her.
Factors considered by courts in determining the best interests of the minor who refuses medical care include, besides her maturity, her religious convictions, her family’s attitude, the effectiveness of the proposed medical treatment, the risk of adverse side effects, the prognosis without treatment, whether treatment can safely be delayed, and the effectiveness of any proposed treatment alternatives.
As Jessica Penkower notes, the “mature minor doctrine” does not really give adolescents autonomy in refusing medical treatment. The best interests of the child standard still applies. No court has given a minor the right to refuse treatment that his parents want him to have. And no reported ruling has provided an explanation of what maturity means when a child chooses to die. Penkower also cites research findings that chronic or severe illness causes more anxiety and despair for adolescents than for adults. It hinders the formation of social and peer relationships, which are so important to teenagers. It may delay puberty or change their appearance in other ways. It exacerbates the feelings of self-doubt and inadequacy common to all teenagers. It increases their dependency on parents at a time when they want to pull away from parents. Those psychosocial factors might influence a teen to refuse medical treatment but be irrelevant to a chronically ill adult.
Evaluating the right of a minor to refuse medical treatment on religious grounds is problematic for many reasons. Jonathan Will calls upon the courts to inquire into whether the teen has the “religious integrity” of “underlying and enduring” values and thus the “… ability to make autonomous decisions.” Religion, however, is a social construct imparted to young children by parents. Furthermore, adolescence is almost by definition a time when new values are being developed.
Canadians Ian Mitchell and Juliet Guichon argue that a teen’s “freedom from coercion” must be established before allowing him to refuse necessary medical care. They point out that the Jehovah’s Witnesses threaten members with shunning and “disfellowshipping” for accepting blood transfusions and hover over members in hospitals. Parents are enjoined to coach and role play with their children on what to say and do to resist transfusions. Children who refuse transfusions are glorified as martyrs to the faith in “Witness” magazines. Mitchell and Guichon ask how a Witness child’s decision to refuse a transfusion could ever be considered truly voluntary.
Furthermore, religious faith is itself generally based on assumptions that are counterintuitive to rational premises. Holding that evolution predisposes humans to have faith, anthropologist Boyer and Walker argue that “… at around age seven the child acquires a conceptual ability that makes his/her religious concepts much more similar to adults’, that is, based on counterintuitive assumptions and clearly distinguished from fiction.” If courts allow minors to refuse lifesaving medical treatment based on their ability to explain their religion, they might find that 7-year-olds do as well as many adults.
A textbook case on how not to let a minor die is that of Dennis Lindberg. The boy was first exposed to the Jehovah’s Witness faith in 2003 when he went to live with his aunt. She became his legal guardian in 2007. On November 8, 2007, less than 2 months after his fourteenth birthday, Dennis was diagnosed with acute lymphocytic leukemia at Children’s Hospital in Seattle with a 75% probability of 5-year survival. Jehovah’s Witness nonrelatives were in his room around the clock. The aunt prohibited his other biological relatives from talking to him about his need for transfusions. His grandmother called several times a day; the hospital would not connect her to him, saying that grandparents had no right to talk to him against his guardian’s wishes.
Although Washington law requires mandated reporters to report child abuse and neglect to Child Protective Services within 48 hours, the hospital told the aunt on November 20 that their lawyers had determined Dennis was “a mature minor” with a legal right to refuse medical treatment. On November 21, however, the hospital reported Dennis to CPS as a neglected child to, as they said, “… cover all bases and to cover the aunt.” But the hospital also told CPS that their physicians thought the boy should be allowed to refuse transfusions. CPS circulated an internal memo saying they could not go to court to seek an order for transfusions because the doctors would not support it. In fact, however, CPS did have a legal right to petition the court.
On November 26, the boy’s parents in Idaho were made aware that they could contact CPS and told the agency they wanted their son to have transfusions. CPS asked for a court hearing to be held the next day and flew the parents to Seattle to testify. In court the treating physician testified that Dennis still had a 70% chance of recovery with transfusions, but that he and other physicians on the team considered the boy a mature minor with the right to refuse life-saving medical treatment. He also said he had let other Jehovah’s Witness children refuse transfusions and later regretted it. The judge did not see or hear from the boy since Dennis was by then comatose. The next day the judge ruled that Dennis had the right to refuse transfusions because, according to the media in attendance, the boy had religious beliefs against them and because he was mature enough to understand that he “… was basically giving himself a death sentence.” Non-Witness friends and relatives attending the hearing said the judge cited no case law or statutes as the basis for his ruling. CPS did not appeal. The boy died later that day. Records of the hearing and ruling are sealed.
Redacted CPS records shown to the boy’s parents indicate cursorily that Dennis was “mature, articulate, and adamantly opposed to transfusions,” but also indicate that no psychological evaluation was done on the child. They show no awareness of the tremendous social pressure on him with Witnesses around the world praising his refusal on a public webpage, nor of the isolation from non-Witness relatives and friends imposed by his guardian.
Neither competence in explaining religious belief, understanding the benefits and risks of a proposed medical treatment, nor understanding the consequences of refusing treatment justify preventable deaths of children. Surely a minor’s understanding that he will die without treatment is not a sufficient basis for letting him do it. Surely a higher bar should be set for a life-and-death decision than for other medical decisions that state laws allow teenagers to make on their own. The “mature minor doctrine” does not really give teens autonomy and is insidiously tied to policies that undermine our social contract to protect vulnerable children.
At the very least, no hospital should determine on its own that a child has a right to die a preventable death. All mandated reporters should promptly report a family’s refusal of necessary medical care to state child welfare services, which should evaluate the psychosocial pressures upon the child. The state should promptly petition the court to order medical care, and if the court refuses to order it on the basis of a minor’s maturity or religious beliefs, the state should appeal the ruling. At present we have no public records indicating how a court has evaluated a child’s maturity and decided to allow a child to refuse care.
States do not allow minors to smoke, drink alcohol, play the lottery, obtain a chauffeur’s license, or sign an enforceable contract. The U.S. Supreme Court recently prohibited execution of those who commit crimes as minors. In those respects society acknowledges that teenagers’ decision-making skills are not fully formed, and we should protect them from harmful or irreversible consequences of their decisions. Obviously the state should not impose medical treatment on children of any age if it merely prolongs dying, is only experimental, or has risks and side effects that outweigh its benefits. In this writer’s view, however, the state should require that parents provide minors up to the age of 18 with the necessities of life, including medical treatment when it has a good probability of preserving life, preventing permanent harm, or significantly improving quality of life.
This should be done not only because of the state’s parens patriae obligation to children but also because society needs these children. As the U.S. Supreme Court held in Prince , our “… democratic society rests, for its continuance” upon children growing “into full maturity as citizens.”
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
