Professor Silverman's article examines the complex challenges faced by U.S. policymakers attempting to balance the public health protections of mandatory childhood immunization programs with the legal, religious, philosophical, and practical concerns raised by permitting non-medical exemptions under the programs. The article begins with a discussion of the history of childhood immunization programs, and continues by describing the inconsistency of enforcement of state immunization laws and exemptions. The author analyzes recent cases from New York, Wyoming, and Arkansas, and discusses how these decisions both pose threats to these programs' public health protections, while also offering insight into potential problems for other state vaccination programs. Professor Silverman concludes by advocating that states adopt an "informed refusal" approach to vaccination exemption as a way of improving immunity protections, while respecting the autonomy rights of those who wish to opt out of the program.

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