Jessica Crank had a swollen shoulder. Not just swollen: In May 2002, when the teenager’s mother, Jacqueline, finally took her to a walk-in clinic in Lenoir City, Tennessee, the nurse practitioner found signs of bone disintegration and “other indications of a serious medical condition” on the x-ray. She called the University of Tennessee emergency room and had them prepare for Jessica’s arrival and urgent treatment.

But Jessica never made it to the E.R., just as she and her mother didn’t show up at the hospital when a chiropractor had urged them to seek medical care earlier in February. Instead, as Jaqueline Crank later testified in court, she chose to turn to “Jesus Christ, my Lord and my Savior, my Healer, Defender, for [Jessica’s] healing.”

Crank “knew there was a problem” with the “grapefruit-sized tumor” on her daughter’s shoulder. But she believed Jesus “was the only Healer,” she said, “and through that belief we took it in our hands to pray for her, to heal her with prayer.”

It did not work. After the walk-in-clinic nurse called the police and Jessica was taken to the hospital, she was diagnosed with Ewing’s Sarcoma, a rare form of cancer. Getting medical care sooner likely wouldn’t have saved her, but it would have helped manage her symptoms and “positively impacted the quality of her life,” her pediatric oncologist testified. Jessica died in state custody at the age of 15.

Crank was found guilty of misdemeanor child neglect, along with the man she was living with, Ariel Ben Sherman, who had founded a small prayer group called the Universal Life Church a year earlier in Lenoir City. Their defense, they argued, was right in the Tennessee Code Annotated: Under state law, it wasn’t considered abuse or neglect for parents to seek “treatment by spiritual means through prayer alone” in lieu of medical care for their kids.

The case made it all the way up to the Tennessee Supreme Court. Sherman died while the case was on appeal, but Crank’s conviction was upheld: Because she wasn’t part of a “recognized church or religious denomination,” the Court held, she wasn’t entitled to the faith-healing defense. Her sentence was affirmed: Eleven months and 29 days, to be served on unsupervised probation.

The Court didn’t strike down the law, but one year later, the Tennessee legislature acted. This spring, it quietly repealed the faith-healing exemption in its child-neglect law, becoming one of just a handful of states that don’t provide any religious exemptions to civil or criminal charges of child neglect or abuse.

Religious-freedom fights often focus on issues of speech and prayer, of worship spaces and safe observance. Exemptions to charges of child abuse, however, rarely get that kind of attention. The laws are just there, sitting on the books, waiting for a kid to die before they get repealed.

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Of all the people governments act to protect, children are perhaps the most vulnerable. Despite federal laws that seek to protect kids under 18 from neglect and abuse, there is no one definition across states of what “abuse” actually means, especially when it comes to families who rely on prayer and faith healings in place of medical care. In some places, if a child is injured, or dies, parents can use their state’s religious exemption as a defense against criminal charges.

The federal government started pushing states to pass these laws starting in 1974 under Richard Nixon’s administration. Largely because of lobbying efforts by Christian Scientists, the Department of Health, Education, and Welfare, which later became the Department of Health and Human Services, determined that parents who don’t seek traditional medical care for their kids for religious reasons should not be held negligent. The agency threatened to withhold federal funding from states that didn’t allow similar accommodations. One by one, states codified religious defenses into their child abuse, endangerment, and neglect laws. Even as federal law has changed over the years, most of these laws have stayed on the books, equally distributed across states red and blue.

A few legislatures have changed their laws; like Tennessee, most states only take action after hearing harrowing reports. A few months after the Tennessee Supreme Court ruled in the Crank case, a lobbyist named Chris Ford, who had been hired by the American Academy of Pediatrics and an advocacy group called Children’s Healthcare Is a Legal Duty, or CHILD, approached Senator Richard Briggs about the possibility of sponsoring a repeal bill. The Knoxville surgeon and legislator said yes, although he was wary of potential attacks from religious-freedom advocates and those who oppose “big government.”

In this deeply conservative state—which, in its last legislative session, very nearly declared the Bible its official book, and passed a controversial religious-conscience exemption for counselors who don’t want to treat LGBT patients—this bill could have triggered an intense fight. “People were asking me, ‘Why do you want to take this on?’” Briggs said.

It’s possible Tennessee conservatives thought the child-neglect issue was a political loser.

Some of the state’s conservative groups came to see him with potential concerns, including Bobbie Patray, the head of the Tennessee Eagle Forum—the late Phyllis Schlafly’s organization—and David Fowler, whose group, the Family Action Council of Tennessee, routinely pushes legislation on conservative social issues in the state. (Patray and Fowler both declined to comment on their involvement in the repeal process.)

Neither group ended up taking on the issue; Briggs said he persuaded them by comparing the exemption to supporting abortion—because life matters before and after birth—and allowing “fundamental Muslims [to practice] sharia law.” (All observant Muslims would likely say they’re following sharia law; Briggs was specifically referring to some non-American Muslims’ practice of stoning women, he said.) It’s also possible that, following a sad and controversial court case over a teenage girl’s death, Tennessee conservatives simply thought the child-neglect issue was a political loser.

Others who expressed concerns were Christian Scientists. When Tennessee added a religious exemption to its child-welfare laws in 1994, according to court documents of the hearing records, a member of the Senate Judiciary Committee noted that it “was offered by the Christian Scientists, and it ensures that they are protected.”

Over the past four decades, Christian Scientists have often been involved in efforts to add religious-exemption language into child-welfare laws. The denomination, founded in 1879 by Mary Baker Eddy, emphasizes the importance of spiritual healing, which can include the physical body. When faced with medical challenges, including an on-going health issue or emergency, individual Christian Scientists can choose to seek traditional medical help, or they can rely on prayer and guidance from Christian Science practitioners who are trained in the art of faith healing.

The group has lobbyists in each state to watch for legislation affecting their faith, said Debbie Chew, the Christian Science contact in Tennessee. The “Church really doesn’t get into the legislative process,” including drafting or pushing for specific bills, she claimed. But “if there’s something that really is going to affect Christian Scientists, we might jump in there and ask for an accommodation.” Ultimately, the Christian Scientists decided not to take a position on the Tennessee repeal bill. The law was “never [intended] to shield reckless parents or to leave children unprotected,” Chew said.

When Tennessee’s repeal bill came to a vote at the very end of the term, it passed nearly unanimously, with no floor debate. What could have been a major legislative fight went through with little note. Other states haven’t had such smooth experiences: In Idaho, children who are part of a group called the Followers of Christ have reportedly been dying of treatable and preventable illnesses at rates much higher than the national average. In next-door Oregon, outcry over the practices of the same group eventually led legislators to repeal the state’s child-welfare exemptions for faith healing and prayer. So far, the Idaho legislature has refused to change its child-welfare laws along those lines.

Meanwhile, religious defenses against child-abuse charges have recently been in the news. This summer, an Indiana woman used the state’s newly passed Religious Freedom Restoration Act, or RFRA, as an argument against felony child-abuse charges. Prosecutors allege she beat her son with a coat hanger, leaving 36 bruises; she justified her actions via scripture, arguing that “[sparing] the rod spoils the child.”

By the time these laws do get used in court, the worst has often already happened.

Cases like this can seem like liberal catastrophizing come to life: Some opponents of RFRAs have claimed such laws give religious parents cover for abusing and neglecting their children. In reality, legal experts say, it’s unlikely that the Indiana statute will actually shield the mother from charges. “Literally nobody believes that general religious-liberty provisions like RFRA create a defense for injuring a child, or injuring an adult, for that matter,” said Douglas Laycock, a law professor at the University of Virginia.

Specific, state-level exemptions, like the former law in Tennessee, focus on faith healing, prayer, and parents’ obligation to seek formal medical care. Different laws protect parents against charges ranging from misdemeanor neglect to capital murder, which is the case in Arkansas. One reason why many states haven’t revisited their religious exemptions to child-welfare laws is that they’re not used that often in criminal cases, according to the heads of a half dozen chapters of the American Civil Liberties Union in the states that have the most permissive laws. But when the relatively rare cases of faith healings do come up, “there [those statutes] are, and they protect conduct that probably should not have been protected,” Laycock said.

The case of the coat-hanger beating in Indiana, along with Jessica Crank’s death in Tennessee, offer an interesting study in contrasts. News of gruesome child deaths or injuries that are justified by religious freedom seems to get selective coverage, depending on the laws at hand. In a place like Indiana, where the law in question is already politically charged and associated with fights over LGBT rights, an alleged child-abuse case might get a lot of attention. In Tennessee, however, repeal of the law’s faith-healing exemption brought barely a whisper of conversation.

Thanks to uneven state laws, charges might not even be brought in similar cases in other places: Before Oregon’s child-welfare laws were revised, for example, prosecutors declined to bring cases against Followers of Christ whose children died from treatable or preventable ailments—technically, their behavior wasn’t illegal. In most states, these provisions remain tucked in the depths of codebooks, dusty and forgotten. By the time they do get used in court, the worst has often already happened—it can take an intervention by child services or reports of a severe injury for these kinds of parental choices to become public.

It may take a case like Jessica Crank’s to get legislators to act. It’s change, at the price of a child’s life.