By Michelle Bach.
Even before the coronavirus pandemic, the WHO named vaccine hesitancy as one of the top ten threats to global health. The WHO attributes vaccine hesitancy to factors such as a lack of confidence, complacency, and convenience. In the UK, hesitancy has been associated with certain demographic factors such as race, age, and socioeconomic factors. Race is an important factor in vaccine hesitancy, and is indicative of injustice in access and well-founded mistrust based on historic medical experimentations on people of color. But race, confidence in the vaccine science, complacency and convenience are only part of the story. So often, I’ve seen clinicians and ethicists argue for vaccination based on the facts: The science supports vaccination, we say. We tell patients that rational risk assessment favors vaccination. We believe that if we just adequately inform the public about the safety and benefit, people will do the right thing. But this approach just misses a fundamental truth: For many anti-vaxxers, it’s was never about facts. Instead, among a certain population, vaccine refusal is better understood as a culture of 1) Anti-institutionalism 2) Aspiration and 3) Aesthetics. Heidi Larson, head of the Vaccine Confidence Project, is right when she says “…there’s all this focus on the public understanding the science. I think we’re not focusing enough on scientists understanding the public.”
It’s intuitive to discuss the science behind vaccines with patients because you and I both know that scientific studies support the safety and efficacy of vaccines. But for a subset of anti-vaxxers, this is an automatically losing strategy because they connect their personal identity with anti-institutionalism. They identify as free thinkers, and part of that identity involves a rejection of “Big Pharma” and the medical institution as a whole. It’s no coincidence that vaccine hesitancy is more prevalent among populists. Explore social media for anti-vaxx tags like #HealthFreedom, #truthseekers, #exitthematrix, and #BigPharma and you’ll see anti-vaccination posts that say things like “Independence and health go hand and hand” and “human sovereignty” means not listening to scientific and governmental institutions. There’s an emphasis on not being “compliant” and seeking out one’s own information away from doctors (t-shirts that say “but first read the insert” are available). Perhaps this is the fallout of decades of magazine articles and television segments titled “What Doctors Don’t Want You to Know.” Before we try to convince patients, we need to recognize that for some, their identity is tied up with not being convincible.
The anti-vaxx culture is not about a lack – a lack of confidence, a lack of information, a lack of motivation to be healthy. In fact, the anti-vaxx culture is full of positive values. It is better to understand anti-vaxx culture as aspirational. Many anti-vaxxers are seeking a particular vision of health empowerment. They want to see health as within their own control and knowable through their own intuitions and common sense. This brand of vaccine hesitancy/resistance is linked with the home and “natural” birth movement, where the belief is that we all are equipped with what we need for our own health and the health of our children. The anti-vaxx hashtag, #BelieveMothers promotes the idea that a mother’s intuition may be enough to achieve ideal health. We see a plethora of Facebook and Instagram posts that claim achieving health is “simpler and easier than you think,” just a matter of “self-love”, and that we all “already have all we need” to achieve health. We might call this a bootstrap vision of health, where hard work, clean eating, exercise, and individual intuition is the key to well-being.
The most neglected aspect of vaccine hesitancy and resistance is the aesthetic appeal of the movement. Doctors have an uphill battle in persuading people that a sterile vile in a sparse clinic room is the key to freedom and safety. It’s much more aesthetically pleasing to turn to the beige and pastel themed social media posts that claim viruses are natural, illness is natural, and one’s natural immune system (untouched by vaccines) is intrinsically good and even beautiful. The hyper-emphasis on the “natural” and “organic” (be it food, décor, essential oils, sustainable fabrics, or letting kids get chickenpox) is an aesthetic choice. There’s simply more appeal to the “mother-nature quality” of holistic approaches compared to the austere, confusing, and even ugly visage of clinical medicine.
Is it permissible to make irrational arguments for vaccination?
Liberalism limits one’s freedom to make irrational decisions (consider for instance John Stewart Mill’s bridge example) and we generally require healthcare decision makers to prioritize rationality and reasonableness (including parents making vaccine decisions for their children). But of course, as humans, many of our decisions are not rational. So often, we go by our guts and our traditions. Doctors and public health officials should be allowed to recognize and respond to that aspect of the human condition. Clinicians will have to do a lot of work to be able to speak the language of anti-institutionalism, health aspiration, and naturalist aesthetics. But it’s possible. We might even call it a new form of “cultural competency”.
Author: Michelle Bach
Affiliation: Center for Health Care Ethics Saint Louis University
Competing interests: None