The recent arrival of effective vaccines against SARS-CoV-2 was a major scientific and public health triumph over a devastating pandemic that has already resulted in more than 500,000 deaths in the United States. But as we’re seeing, the scientific advances that made this vaccine possible is just the first step. We will not succeed unless we figure out how to get the vaccine into enough people’s arms. This includes complicated logistics of vaccine distribution across the entire country to communities large and small. Even with flawless vaccine distribution though, public health experts expect that a significant portion of the US population will be hesitant to accept the vaccine.
Vaccine hesitancy is not unique to the SARS-CoV-2 vaccine as evidenced by the extensive literature on the phenomenon particularly with pediatric vaccines. There are some unique elements to the current pandemic that are relevant for consideration, however. Although vaccine hesitancy for COVID-19 has been declining since September 2020, so called “nonintent” to receive the SARS-CoV-2 vaccine is currently at 32%, which is high enough to potentially impair an effective public health response to hasten the end of the pandemic.1 Those who do not intend to receive the vaccine among those surveyed included younger adults, women, non-Hispanic Black adults, adults living in nonmetropolitan areas, adults with less education and income, and those without health insurance. The most commonly cited reasons for nonintent were concerns about vaccine side effects and safety, lack of trust in the government, and concern that the vaccines were developed too quickly. Initial strategies to address this hesitancy include public health educational campaigns, trusted counseling from a patient’s healthcare professional, and ensuring broad and equitable vaccine distribution across all populations.
Another possible approach is to persuade individuals with interactions guided by moral foundations theory. The theory describes the natural inclination to embed moral judgments within decision making.2 It suggests that human beings have innate intuitions that lead them to emotional responses for approval or disapproval. According to the theory, people make decisions based on these (often unconscious) intuitive processes and then after the fact generate reasons and justifications for their decision.3 This plays out, for example, when a person has an automatic moral disapproval of prioritizing vaccines to people who are incarcerated and then works backward to justify that position.
Six moral foundations have been proposed, including care/harm, authority/subversion, loyalty/betrayal, liberty/oppression, purity/degradation, and fairness/cheating. People either uphold these virtues or are vigilant against violations of them. A wide variety of research has tested the application of the moral foundations theory to predicting attitudes about climate change, suicide, philanthropy, and for our purposes, vaccines. Using validated measures of individuals’ morality, one of which is a 30-item questionnaire available at www.moralfoundations.org, investigators can identify the moral valence of the subjects and then associate them with certain attitudes. For example, compared with research subjects who were not vaccine hesitant, subjects who were vaccine hesitant were significantly more likely to have moral foundations that rest on purity and liberty.4 These subjects were more likely to believe that vaccines were impure and should not be allowed to defile the body. They were also more likely to believe that someone should not be coerced to receive a vaccine: They possess an absolute right of liberty to refuse such an intervention.
It does not take a moral philosopher to consider how moral values may have shaped various perspectives related to COVID-19. Widespread arguments over face masking in public traded on ideas about government oppression and individual liberty on one side and fairness and care on the other. It was “don’t tell me what to do” against “masks protect others in our community.” The sides were in some sense debating moral values, not masks, which is part of why it was often difficult to achieve consensus.
Where does this leave us with vaccine hesitancy for COVID-19? First, the messages healthcare professionals are using to persuade patients to accept the vaccine may be falling on deaf ears. If vaccine-hesitant people are influenced by morality related to purity or liberty, then haranguing them about how the vaccine protects themselves or others in their community (ie, appealing to the moral foundation of care) is not likely to change their mind.
Healthcare providers are not likely to have patients in their office fill out a 30-item moral foundation questionnaire, possibly making it difficult to know how they have made personal decisions in the past. Healthcare providers might want to engage patients in conversations to ferret out what sort of language they use to describe making such decisions. For example, do patients talk about loyalty or fairness or liberty in how they make decisions? Tapping into that decision-making process may help to break a logjam when struggling to provide medical advice.
Patients who have previously talked about not wanting to take medication because they prefer natural products may have a moral valence towards purity. Rather than trying to convince them of vaccine efficacy, it may be more effective to say that vaccination boosts the body’s natural defenses against disease and that vaccination keeps the body free (and thus pure) of other dangerous infections. For patients who say the government can’t make them take the vaccine (which is true of course), they may be reflecting their moral valence towards liberty and away from oppression. It might be possible to reframe that perspective using their dominant moral frame by indicating that vaccination helps patients take personal control of their life and allow them to be free to live a healthy life.
Whatever strategy clinicians use to encourage vaccinations, it is important to be respectful and empathize with patients’ concerns and perspectives. Get patients talking to assess what is on their mind and how they make decisions. That is good for patient care and hopefully a more effective way to get more patients vaccinated.
David J. Alfandre MD, MSPH, is a healthcare ethicist for the National Center for Ethics in Health Care (NCEHC) at the Department of Veterans Affairs (VA) and an Associate Professor in the Department of Medicine and the Department of Population Health at the NYU School of Medicine in New York. The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the NCEHC or the VA.
- Nguyen KH, Srivastav A, Razzaghi H, et al. COVID-19 Vaccination intent, perceptions, and reasons for not vaccinating among groups prioritized for early vaccination — United States, September and December 2020. MMWR Morb Mortal Wkly Rep. 2021;70:217–222. doi:10.15585/mmwr.mm7006e3
- Graham, J, Nosek BA, Haidt J, Iyer R, Koleva S, Ditto PH. Mapping the moral domain. J Pers Soc Psychol. 2011;101:366-385. doi:10.1037/a0021847
- Hauser M, Cushman F, Young L, Kang-Xing Jin R, Mikhail, J. A dissociation between moral judgments and justifications. Mind Lang. 2007;22,1–21. doi:10.1111/j.1468-0017.20066.00297.x
- Amin AB, Bednarczyk RA, Ray CE, Melchiori KJ, et al. Association of moral values with vaccine hesitancy. Nat Hum Behav. 2017;1:873-880. doi:10.1038/s41562-017-0256-5