Perry v. Marteney: Medical-Only School Vaccination Exemptions Remain “Generally Applicable”; Mahmoud/Yoder Parental-Rights Strict Scrutiny Does Not Displace Jacobson/Prince in Public-Health Mandates

Court: United States Court of Appeals for the Fourth Circuit (Published)  |  Case: Krystle Perry v. Stacy Marteney, No. 24-2132  |  Date: April 8, 2026  |  Disposition: Preliminary injunction reversed and remanded

1. Introduction

This appeal arose from a conflict between parental religious objections to vaccination and West Virginia’s compulsory school immunization regime. Plaintiffs Anthony and Krystle Perry sued on behalf of their minor daughter, K.P., after K.P. was disenrolled from a West Virginia public online program (the Virtual Academy) for not being fully vaccinated. West Virginia law mandates vaccination for school attendance and permits only medical exemptions; it does not provide religious exemptions.

The district court granted a preliminary injunction allowing K.P. to re-enroll while litigation proceeded, concluding the Perrys were likely to succeed on their Free Exercise claim. The Fourth Circuit reversed, holding the statute likely constitutional and therefore preliminary relief unwarranted.

Key issues

• General applicability: Does a medical-exemption process involving medical judgment create an “individualized exemption” mechanism under Fulton v. City of Philadelphia that triggers strict scrutiny?
• Comparability / underinclusiveness: Do statutory distinctions (e.g., homeschooling vs. public virtual schooling) defeat general applicability under Tandon v. Newsom and Fulton?
• Parental-rights cases: Do Wisconsin v. Yoder and Mahmoud v. Taylor require strict scrutiny for vaccination mandates affecting children’s access to public education?
• Virtual schooling: Is it irrational to apply vaccination requirements to students enrolled in a public virtual school?

2. Summary of the Opinion

The majority (Judge Wilkinson, joined by Judge Agee) held that West Virginia’s vaccination requirement for school attendance is a constitutional exercise of state police power to protect public health. Because the statute is neutral and generally applicable, Smith controls and rational-basis review applies. The court concluded the statute easily satisfies rational-basis review and that neither the medical exemption process nor various statutory classifications convert the law into a strict-scrutiny case.

The court also distinguished Mahmoud v. Taylor and Wisconsin v. Yoder as involving ideological or values-based burdens on religious upbringing, not health-and-safety mandates like vaccination. It relied heavily on the historical and precedential line from Jacobson v. Massachusetts, Zucht v. King, and Prince v. Massachusetts.

Dissent (Judge Niemeyer): would have affirmed the preliminary injunction, arguing strict scrutiny should apply because West Virginia treats comparable “remote learning” contexts more favorably (homeschooling, learning pods, microschools), and because Mahmoud v. Taylor (and subsequent Supreme Court actions like Miller v. McDonald and Mirabelli v. Bonta) require heightened protection for parents guiding children’s religious development when public educational benefits are conditioned on burdens to religious exercise.

3. Analysis

3.1 Precedents Cited

A. State police power and compulsory vaccination: the Jacobson line

• Jacobson v. Massachusetts (1905): The cornerstone for the majority’s approach. The court quotes Jacobson for the proposition that the state police power “embrace[s]” reasonable regulations to protect public health and safety, and uses Jacobson to situate vaccination mandates as paradigmatic health legislation. The majority also draws on Jacobson’s social-order rhetoric (the danger of each person becoming “a law unto himself”).
• Zucht v. King (1922): Treated as confirming that Jacobson “settled” the constitutionality of compulsory vaccination, including in the school context.
• Prince v. Massachusetts (1944): Central to the majority’s rejection of parental/religious objections in the child-health context. The opinion quotes Prince for the proposition that parental religious claims do not include “liberty to expose the community or the child to communicable disease.”

B. The Free Exercise framework: Smith, neutrality, and general applicability

• Employment Division, Department of Human Resources of Oregon v. Smith (1990): The majority treats Smith as the operative doctrinal gatekeeper: neutral, generally applicable laws receive rational-basis review and do not require religious exemptions. The court underscores Smith’s explicit warning that heightened scrutiny would invite exemptions from “almost every conceivable kind,” including “compulsory vaccination laws,” and notes Smith’s favorable citation to Cude v. State.
• Cude v. State (Ark. 1964): Used as an exemplar, via Smith, that vaccination requirements do not violate constitutional rights “on religious grounds or otherwise.”
• City of Boerne v. Flores (1997): Cited for the statement that Smith allows neutral, generally applicable laws to be applied even without a compelling interest—supporting the majority’s insistence that strict scrutiny is not the baseline.

C. General applicability and individualized exemptions: Fulton and Sherbert

• Fulton v. City of Philadelphia (2021): The centerpiece for the district court’s strict-scrutiny path (and the majority’s rejection of it). The majority reads Fulton as targeting exemption systems that “invite” officials to weigh reasons for noncompliance (i.e., to decide which reasons are “worthy of solicitude”).
• Sherbert v. Verner (1963): Presented (through Fulton) as the classic “individualized exemptions” mechanism—there, “good cause” created a discretionary, reasons-sensitive inquiry.
• Axson-Flynn v. Johnson (10th Cir. 2004): The majority uses Axson-Flynn to draw a line between (i) limited, criteria-bound professional judgments and (ii) open-ended, reason-sensitive exemption systems that trigger heightened scrutiny under Smith/Fulton.

D. Circuit vaccination-exemption decisions

• The majority aligns with a multi-circuit consensus that medical exemptions in vaccination regimes generally do not create Fulton-style individualized-exemption systems: Does 1-6 v. Mills (1st Cir. 2021); We The Patriots USA, Inc. v. Hochul (2d Cir. 2021); Spivack v. City of Philadelphia (3rd Cir. 2024); Doe v. S.D. Unified Sch. Dist. (9th Cir. 2021).
• The Perrys’ cited cases—Dahl v. Bd. of Trs. of W. Mich. Univ. (6th Cir. 2021) and Does 1-11 v. Bd. of Regents of the Univ. of Colo. (10th Cir. 2024)—are distinguished as involving policies that permitted individualized religious exemptions, which West Virginia does not.

E. Comparability and underinclusiveness: Tandon and Fulton

• Tandon v. Newsom (2021) and Fulton v. City of Philadelphia (2021): The majority uses these to insist that general-applicability problems arise when comparable secular conduct is treated more favorably than religious exercise. It reasons that differential treatment between secular categories (e.g., homeschool vs. virtual public school) is not itself a Free Exercise defect unless the religious conduct is what is being comparatively disfavored.
• We The Patriots USA, Inc. v. Connecticut Office of Early Childhood Development (2d Cir. 2023): Quoted for the point that medical exemptions and religious exemptions are not “categorically comparable” when the state interest is health—medical exemptions protect children who cannot safely vaccinate, while religious exemptions increase unvaccinated numbers without the same health justification.
• Miller v. McDonald (2025) (mem.): The majority notes the Supreme Court vacated and remanded a Second Circuit vaccination decision for reconsideration in light of Mahmoud v. Taylor, but insists West Virginia’s law is distinguishable from Mahmoud.

F. Parental-rights and education cases: Yoder, Mahmoud, and related authorities

• Wisconsin v. Yoder (1972) and Mahmoud v. Taylor (2025): The majority treats these as addressing burdens tied to values/ideological formation in schooling, and thus not controlling for vaccination mandates.
• Mirabelli v. Bonta (2026) (per curiam): The majority distinguishes it as a preliminary action not involving a public health measure.
• W. Va. State Bd. of Educ. v. Barnette (1943) and Pierce v. Soc'y of Sisters (1925): Appear in the dissent (and are referenced in the majority through Prince) as part of the background on parental rights and conscience in education.

G. Standards of review and deference

• Polk v. Montgomery Cnty. Pub. Schs. (4th Cir. 2026): Cited for the proposition that neutral and generally applicable laws receive rational-basis review.
• Bethel World Outreach Ministries v. Montgomery Cnty. Council (4th Cir. 2013) and Grace United Methodist Church v. City of Cheyenne (10th Cir. 2006): Used to define rational-basis review.
• Semler v. Or. State Bd. of Dental Exam'rs (1935) and Williamson v. Lee Optical of Okla. Inc. (1955): Invoked to answer underinclusiveness arguments—legislatures may address problems incrementally.
• City of Dallas v. Stanglin (1989), Dandridge v. Williams (1970), and Lindsley v. Natural Carbonic Gas Co. (1911): Reinforce the forgiving nature of rational-basis review for classifications.
• United States v. Skrmetti (2025) (quoting Gonzales v. Carhart (2007)): Cited for state “wide discretion” in medical/scientific uncertainty—supporting legislative primacy in health policy.

H. Procedure and appellate posture

• Air Evac EMS, Inc. v. McVey (4th Cir. 2022): Supplies the abuse-of-discretion standard for preliminary injunction review, with de novo review of legal conclusions.

3.2 Legal Reasoning

A. The majority’s doctrinal architecture: Jacobson/Prince + Smith

The majority constructs a “continuous line” of authority: state police power to protect public health (Jacobson, Zucht) plus the proposition that parental religious objections do not include the right to expose children or communities to communicable disease (Prince), combined with the modern Free Exercise framework that neutral, generally applicable laws do not require religious exemptions (Smith). This yields a straightforward rule for the preliminary-injunction merits inquiry: if West Virginia’s statute is neutral and generally applicable, it gets rational-basis review and is very likely valid.

B. Why the medical exemption process does not defeat general applicability

The district court’s key move was to characterize the medical exemption system as “significant individualized discretion,” analogizing it to Fulton/Sherbert. The Fourth Circuit rejects that analogy by differentiating:

• Reasons-sensitive discretion (problematic under Fulton): where officials decide which motivations justify noncompliance (e.g., “good cause,” “sole discretion”).
• Criteria-bound medical judgment (permissible here): where officials apply defined medical criteria (“contraindicated” or “specific precaution”) to evidence, with a yes/no determination and judicial review.

In the majority’s view, West Virginia’s scheme does not “invite” officials to consider the “particular reasons” for refusal (religious or otherwise); it asks whether vaccination is medically unsafe or medically inadvisable for that child. That distinction allows the court to treat the statute as generally applicable despite individualized application.

C. Why homeschooling and other carve-outs do not create a Free Exercise defect (as framed by the majority)

The Perrys argued the mandate is underinclusive because it does not apply to (1) homeschooled children (and those in “learning pods” or “microschools”), (2) adults working in schools, and (3) medically exempt children—yet it applies to virtual public-school students. The majority answers in two steps:

• Secular/secular distinctions are not the Free Exercise problem. The first two groups are, in the majority’s framing, merely different secular categories; K.P.’s desire to attend virtual public school was not alleged to be religiously motivated, so the differential treatment does not show “religious conduct” is being disfavored as against “comparable secular activity.”
• Medical exemptions are not comparable to religious exemptions in a health regime. The court agrees with We The Patriots USA, Inc. v. Connecticut Office of Early Childhood Development that medical exemptions can advance the same health interest by protecting children for whom vaccination would be harmful, whereas religious exemptions increase unvaccinated numbers without a health justification.

D. The Mahmoud/Yoder argument: “indoctrination” vs. “public health”

The majority treats Wisconsin v. Yoder and Mahmoud v. Taylor as addressing governmental policies that substantially interfere with religious development by exposing children to values hostile to the faith (compulsory attendance in a “hostile” environment in Yoder; “LGBTQ+-inclusive” storybooks in Mahmoud). Vaccination, by contrast, is characterized as a non-ideological health measure: it does not compel instruction praising vaccines, does not expose children to hostile values, and does not operate as a “values curriculum.”

The majority reinforces this distinction by re-centering Prince v. Massachusetts as the parental-rights case that directly addresses communicable disease—thereby denying that Mahmoud/Yoder displace Prince/Jacobson in the vaccination setting.

E. Rational basis and virtual public schooling

On the argument that virtual attendance presents minimal transmission risk, the majority holds that West Virginia may still rationally require vaccination: risk reduction is a legislative judgment; virtual students may still participate in in-person testing and extracurriculars; and the state may proceed “one step at a time” even if the regime is not maximally comprehensive.

3.3 Impact

• Reinforcement of Smith in public-health vaccination mandates: The decision strengthens the position that school vaccination laws with medical-only exemptions remain in the Smith lane—neutral, generally applicable, rational basis—at least in the Fourth Circuit.
• Clarification of Fulton’s “individualized exemptions” in medical contexts: The opinion articulates a concrete boundary: a medical exemption requiring professional judgment does not become a Fulton-style “reasons-sensitive” exemption mechanism when the criteria are medical and cabined (including via review).
• Limitation (as the majority sees it) on Mahmoud/Yoder spillover: The court resists extending parental-rights strict-scrutiny doctrine from curricular/ideological burdens to health-and-safety mandates, emphasizing Prince as the controlling parental-rights precedent for communicable disease.
• Practical litigation consequences: Plaintiffs challenging vaccination requirements in the Fourth Circuit will face a steeper path when the state offers only medical exemptions and can characterize its exemption process as medically criteria-bound rather than reasons-sensitive discretion.
• Doctrinal fault line highlighted by the dissent: The dissent reads Mahmoud v. Taylor (and the Court’s actions in Miller v. McDonald and Mirabelli v. Bonta) as pushing strict scrutiny whenever access to public education is conditioned on burdens to parents’ religious upbringing decisions. That split signals potential Supreme Court interest in reconciling “public benefit conditioning” and “public health mandate” doctrines.

4. Complex Concepts Simplified

Police power

“Police power” is the states’ inherent authority to enact laws protecting health, safety, and welfare. In this opinion, vaccination is treated as a classic police-power measure (Jacobson v. Massachusetts).

Neutral and generally applicable (Free Exercise)

A law is typically “neutral” if it does not target religion, and “generally applicable” if it does not selectively burden religious exercise while leaving comparable secular conduct unburdened. Under Employment Division, Department of Human Resources of Oregon v. Smith, neutral and generally applicable laws ordinarily do not require religious exemptions.

Rational basis vs. strict scrutiny

• Rational basis: the government only needs a reasonable connection between the law and a legitimate interest. It is highly deferential.
• Strict scrutiny: the government must show a compelling interest and that the law is narrowly tailored (no less restrictive means would work). It is demanding.

“Individualized exemptions” after Fulton

Under Fulton v. City of Philadelphia, strict scrutiny may apply if the law includes a mechanism that lets officials grant exemptions case-by-case based on subjective or open-ended judgments about whether noncompliance is justified (e.g., “good cause,” “sole discretion”). The majority holds West Virginia’s medical exemption is not that kind of mechanism because it is tied to medical contraindications/precautions and “sufficient medical evidence,” not to the applicant’s reasons for refusing vaccination.

Contraindication and precaution

A contraindication is a medical condition that makes a vaccine improper for a particular person; a precaution is a condition that may increase the risk or severity of adverse reaction or reduce vaccine effectiveness. West Virginia’s exemption turns on these medical concepts rather than religious conscience.

Preliminary injunction posture

A preliminary injunction is temporary relief granted before final judgment. Here, the Fourth Circuit’s reversal rests on the conclusion that the Perrys were not likely to succeed on the merits—often the most important factor in such motions.

5. Conclusion

Perry v. Marteney reasserts, in emphatic terms, the constitutional durability of school vaccination mandates under the combined force of Jacobson v. Massachusetts, Prince v. Massachusetts, and Employment Division, Department of Human Resources of Oregon v. Smith. The opinion’s most consequential doctrinal move is to hold that West Virginia’s medical-exemption process—though requiring medical judgment—does not create the kind of discretionary, reasons-sensitive “individualized exemptions” system that undermines general applicability under Fulton v. City of Philadelphia. It also draws a sharp line between parental-rights strict-scrutiny cases like Wisconsin v. Yoder and Mahmoud v. Taylor and public-health mandates aimed at communicable disease.

Whether that line remains stable—given the dissent’s competing reading of Mahmoud and the Supreme Court’s recent signals—may determine the next phase of Free Exercise litigation in public health and education.