Moral Judgments and COVID-19 Vaccine Reluctance

The recent introduction of effective vaccines against SARS-CoV-2 was a major triumph for science and public health over a devastating pandemic that has resulted in more than 500,000 deaths in the United States. But as we can see, the scientific advances that have made this vaccine possible are only the first step. We won’t succeed if we don’t figure out how to get the vaccine into the arms of enough people. This involves the complicated logistics of vaccine distribution across the country to communities large and small. Despite a proper vaccine distribution, public health experts expect a significant portion of the US population will be reluctant to accept the vaccine.

The hesitation of the vaccine is not only seen with the SARS-CoV-2 vaccine, as is evident from the extensive literature on this phenomenon, especially for pediatric vaccines. However, there are some unique elements of the current pandemic that need to be considered. Although vaccine hesitation for COVID-19 has decreased since September 2020, the so-called “non-intention” to receive the SARS-CoV-2 vaccine is currently 32%, which is high enough to potentially have an effective public response Affecting health to hasten the end of the pandemic.1 Respondents who did not intend to receive the vaccine included younger adults, women, non-Hispanic Black adults, adults in non-urban areas, adults with less education, and lower income and people without health insurance. The most common reasons cited for non-compliance were concerns about the side effects and safety of vaccines, lack of trust in the government, and concerns that vaccines were being developed too quickly. Initial strategies to address this hesitation include public health awareness campaigns, trusted advice from a patient’s healthcare professional, and ensuring a wide and equitable distribution of vaccines to all populations.

Another possible approach is to convince individuals with interactions guided by the theory of moral foundations. The theory describes the natural tendency to embed moral judgments in decision-making.2 It suggests that people have innate intuitions that lead them to emotional responses to approval or disapproval. According to the theory, people make decisions based on these (often unconscious) intuitive processes and then subsequently generate reasons and justifications for their decision.3 This happens, for example, when a person has an automatic moral rejection of prioritizing vaccines for people who are incarcerated and then work backwards to justify this position.

Six moral foundations were suggested including caring / harm, authority / subversion, loyalty / betrayal, freedom / oppression, purity / humiliation, and fairness / fraud. People either cling to these virtues or are vigilant against violations of these virtues. Much research has tested the application of moral foundations theory to predicting attitudes toward climate change, suicide, philanthropy, and, for our purposes, vaccines. Using validated measurements of people’s morale, one of which is a 30-point questionnaire available at, investigators can identify subjects’ moral worth and then link them to specific attitudes. For example, subjects who did not hesitate against vaccines were significantly more likely to have moral foundations based on purity and freedom compared to subjects who did not hesitate against vaccines.4 These subjects were more likely to believe that vaccines were impure and will not be approved should pollute the body. They were also more likely to believe that someone should not be forced to get a vaccine: they have an absolute right to refuse such intervention.

It doesn’t take a moral philosopher to ponder how moral values ​​could have shaped different perspectives on COVID-19. Widespread arguments about face masking in public were about ideas about state oppression and individual freedom on the one hand and fairness and diligence on the other. It was “don’t tell me what to do” versus “masks protect others in our community”. The sides discussed, in a way, moral values, not masks, so it was often difficult to reach consensus.

Where’s the vaccine hesitation for COVID-19? First, the messages used to convince patients to accept the vaccine may fall on deaf ears. If vaccine reluctant people are influenced by morals about purity or freedom, they are unlikely to change their minds when they talk about how the vaccine protects themselves or others in their community (i.e., addresses the moral basis of care) .

Healthcare providers are unlikely to have patients complete a 30-point moral questionnaire in their office, which can make it difficult to know how they have made personal decisions in the past. Healthcare providers may want to involve patients in conversations to find out what language they are using to describe such decisions. For example, do patients talk about loyalty, fairness, or freedom when making decisions? Using this decision-making process can help clear a traffic jam if you are having trouble providing medical advice.

Patients who have previously spoken of not wanting to take medication because they prefer natural products may have a moral value over purity. Rather than trying to convince them of the vaccine’s effectiveness, it may be more effective to say that vaccination strengthens the body’s natural defenses against disease, and that vaccination keeps the body free (and therefore clean) of other dangerous infections. Patients who say the government cannot get them to take the vaccine (which it does, of course) may reflect their moral worth to freedom and oppression. It may be possible to redefine this perspective based on its prevailing moral framework, stating that vaccination helps patients take personal control of their lives and give them the freedom to live healthy lives.

Regardless of the strategy clinicians use to promote vaccination, it is important to be respectful and empathize with patient concerns and perspectives. Let patients speak to assess what they think and how they are making decisions. This is good for patient care and hopefully a more effective way to get more patients vaccinated.

David J. Alfandre, MD, MSPH, is a health ethicist at the Department of Veterans Affairs (VA) National Center for Health Ethics (NCEHC) and Associate Professor in the Department of Medicine and Department of Population Health, NYU School of Medicine, New York . The views expressed in this article are those of the author and do not necessarily reflect the position or policies of the NCEHC or the VA.


  1. Nguyen KH, Srivastav A., Razzaghi H. et al. COVID-19 Vaccination Intent, Perceptions, and Reasons for Not Vaccinating in Groups Prioritized for Early Vaccination – USA, September and December 2020. MMWR Morb Mortal Wkly Rep. 2021; 70: 217-222. doi: 10.15585 / mmwr.mm7006e3
  2. Graham, J., Nosek BA, Haidt J., Iyer R., Koleva S., Ditto PH. Illustration of the moral domain. J Pers Soc Psychol. 2011; 101: 366- 385. doi: 10.1037 / a0021847
  3. Hauser M., Cushman F., Young L., Kang-Xing Jin R., Mikhail, J. A Dissociation Between Moral Judgments and Justifications. Mind long. 2007; 22.1-21. doi: 10.1111 / j.1468-0017.20066.00297.x
  4. Amin AB, Bednarczyk RA, Ray CE, Melchiori KJ et al. Association of moral values ​​with vaccine reluctance. Nat Hum Behav. 2017; 1: 873-880. doi: 10.1038 / s41562-017-0256-5

This article originally appeared in the Renal and Urology News

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