Most states that offer nonmedical exemptions for children to attend school without vaccinations require parents to do nothing more than declare they want an exemption.1 States like Oregon and Utah require some type of education as part of the process, but such learning usually can be completed online. (Colorado lawmakers are considering implementing a similar process.)2-4

Since 2015, Michigan has required local health departments to be the designated educators.5 “Advocates of this new policy hoped that parents would change their minds after education sessions, which does not seem to have happened,” says Mark Navin, PhD, professor of philosophy and lecturer in foundational medical studies at Rochester, MI-based Oakland University. Almost everyone who attended an education session received an exemption, which seemed to defeat the purpose of the program. Exemption rates did decline slightly, but it was apparently because some parents decided to vaccinate their children instead of attending mandatory sessions.

“This focus on the behaviors of parents, and the vaccination status of children, ignored the burdens that were being imposed on local health staff,” Navin says.

To learn more about this, researchers conducted focus groups with 37 public health nurses in 2016 and 2017.6 Most participants expressed a strong commitment to respect parents’ values, even if they personally disagreed with them. A strong ethical focus emerged in the discussions.

“We were surprised that so many participants made nuanced ethical arguments about their work providing immunization education,” Navin reports.

On the one hand, public health nurses criticized vaccine-refusing parents for failing to protect their children and the community. At the same time, they commended those parents for attempting to do what they thought was best for their children. “Our participants insisted that immunization was centrally important,” Navin says.

However, focus group participants expressed mixed feelings about whether the government should remove unvaccinated children from school. “The staff we spoke with also expressed concern about whether it was good for public health to be providing mandatory education,” Navin says.

Some nurses believe it made more sense for primary care providers to take on this role, since they already had existing relationships with the families. Other participants were uncomfortable with their role in a coercive government program. They are expert health educators, but are used to working with voluntary participants, not with people who were forced to come to the health department, Navin explains.

The researchers also wanted to call attention to the underused expertise of public health nurses in general. “Physicians play a large role in national debates about immunization policy,” Navin notes.

Professional societies continue to lobby for stricter vaccine mandate policies, including the elimination of nonmedical exemptions.7,8 “But public health staff also have expert knowledge about immunization policies, and about the people and communities those policies affect,” Navin observes.

Debates on how to best respond to outbreaks of vaccine-preventable infections are continuing. “We would do well to draw on ethical insights from frontline public health professionals,” Navin concludes.


  1. National Conference of State Legislatures. States with religious and philosophical exemptions from school immunization requirements. Updated Jan. 3, 2020.
  2. Oregon Health Authority. Nonmedical vaccine exemptions.
  3. Colorado General Assembly. SB20-163. School Entry Immunization. Under consideration (as of June 10, 2020).
  4. Utah State Legislature. H.B. 308. Public Health and Schools. Signed into law March 24, 2017.
  5. Navin MC, Tozak AT, Clark EC. The evolution of immunization waiver education in Michigan: A qualitative study of vaccine educators. Vaccine 2018;36:1751-1756.
  6. Navin MC, Kozak AT, Deem MJ. Perspectives of public health nurses on the ethics of mandated vaccine education. Nurs Outlook 2020;68:62-72.
  7. American Medical Association. AMA policy advocates to eliminate non-medical vaccine exemptions. June 13, 2019.
  8. AAP News. Elimination of non-medical vaccine exemptions ranked top priority at Annual Leadership Forum. March 16, 2019.