It will take more than just the facts to persuade our vaccine hesitant family and friends to book their jab. Trust is also vital. And if in doubt, genuinely listening to their fears will always go a long way, writes medical ethicist Denise Cooper-Clarke.
By Denise Cooper-Clarke
28 September 2021
Aristotle famously described three modes of persuasion. Logos refers to the argument itself, an appeal to reason, ethos refers to the character of the speaker, and pathos to an appeal to the hearer’s emotion. Success in persuasion depends not only on a sound argument, but on gaining trust and arousing emotions in the audience that makes them more receptive to the argument. For Aristotle, while all three modes are important, pathos is subordinate to ethos and ethos subordinate to logos. The argument itself is the essential and most effective mode of persuasion.
When we turn to bioethical discussion of the legitimate means by which health practitioners may influence their patients’ decision-making, the emphasis is almost exclusively on logos. Principles of Biomedical Ethics defines persuasion as “influence where a person comes to believe in something through the merit of reasons another person advances”.
Even such purely rational persuasion by doctors is regarded by some as an illegitimate infringement of patient autonomy. On this view, doctors should not attempt to influence their patients’ decisions in any way, but simply present the medical facts and allow the patient to choose. But it is open to question whether medical “facts” can be communicated without influencing how the “facts” are perceived. Doctors communicate their value judgements about potential treatments, consciously or unconsciously, through non-verbal cues such as tone of voice and body language. In addition, the “framing effect” means patients make choices based on whether the options are presented with positive or negative connotations, such as the chances of survival versus the risk of mortality.
Further, the model of doctors as value-neutral “fact providers” is implausible because medicine is a moral practice with inherent values. Doctors place great value on good health. I believe it is both permissible and necessary for them to engage in rational argument to persuade patients to make medical decisions that the doctor believes are in the patients’ best interests.
Some patient choices are regarded as bad by doctors, such as smoking, failure to have regular cancer screening or refusal to vaccinate children without a medical exemption. The biases that underline some of these choices include being influenced unduly by recent, rare and vivid events, being influenced more by short term concerns than long term goals, preferring inaction to avoid harm even if this may lead to greater harm, being unduly influenced by unrelated events, and continuing with a plan of action even when it becomes clear that it is not beneficial, because one is invested in that decision.
All of these factors may be observed in the phenomenon of vaccine hesitancy.
When we turn to discussion of how public health communication may influence behaviour, the literature suggests that only persuasion that appeals to reason is valid. This is distinguished from coercion (use of a threat) and manipulation, that attempts to bypass reason. But it is possible to appeal to emotion without intending to coerce or manipulate. Thus, the door is left open for pathos.
It is difficult to see how communication of medical facts or arguments can avoid also appealing to pathos. Fear and anxiety are often induced, whether intended or not, when serious risks of illness and death are raised.
The decision to be vaccinated against COVID-19 involves both a medical and a moral judgement. Since vaccination rates affect the whole of the Australian community, indeed the global community, it is not simply a question of “What is best medically for me?” but “What ought I to do?”.
Are moral judgements made solely or primarily on the basis of logos? Moral psychologist Jonathan Haidt argues rather that they are largely intuitive, with reason involved only after the fact to justify them. We are not as rational as we think we are. People seldom change their minds as a result of rational persuasion, but through appeals to their intuitions and instinct.
How does this play out in the phenomenon of COVID vaccine hesitancy?
Appeal to logos seemed to be the basis of the federal government’s first vaccination campaign, which featured medical experts calmly outlining the benefits of COVID-19 vaccination. The message was that the vaccine is safe, effective and free. The campaign also appealed to ethos, using medical doctors and clinical experts.
The campaign was launched in late January 2021. A poll in mid-May showed that vaccine resistance and hesitancy was high: 15 per cent of Australians said they were not at all likely to be vaccinated and a further 14 per cent that they were not very likely to be. A major factor in this was undoubtedly the emergence of the very rare risk of blood clotting with the AstraZeneca vaccine. Another was complacency. At that stage there was little community transmission of COVID-19. Yet there was also considerable criticism of the vaccination campaign as ineffective, boring and banal. One advertising executive said, “There’s plenty of evidence recently that rational campaigns can only do so much … emotions win and emotions drive behaviour.”
It is clear that fear is a major driver of both COVID-19 vaccination and vaccine hesitancy. Fear of COVID-19 outbreaks such as those seen in NSW and Victoria drives vaccinations up. Fear of side effects drives vaccination rates down, as when the complication of a clotting disorder with the AstraZeneca vaccine was publicised. More recently, fear of prolonged lockdowns has driven vaccinations up, most notably in NSW. Alternatively, this could be framed in terms of a positive effect of pathos: the hope of enjoying greater freedoms.
But other media experts suggest the campaign should appeal to ethos: Who do Australians look up to and listen to? They argue it’s not enough to get the science right, the message matters and so does the messenger. And they say this is a matter of building and restoring trust.
Trust is the key element in persuasion using ethos. Lack of trust in health care systems, in pharmaceutical companies and in government, is a major factor in vaccine hesitancy and resistance globally. Conspiracy theories abound both in relation to the virus and the vaccines. Trust depends on a number of social, political, historical and religious factors, that differ in different communities.
In the United States, before COVID-19 vaccinations began, it was predicted that Black Americans would have lower vaccination rates because of historic mistrust in the government, the health system and the medical profession, a legacy of the Tuskagee Syphilis experiment and the case of Henrietta Lacks. However a recent study showed that black Americans are more likely to trust information if it comes from a black doctor, someone who looks and speaks like them. As only five per cent of US doctors are black, it was recognised that other trusted leaders in black communities were also required to reinforce the pro-vaccination message.
In England, four months after COVID-19 vaccination began, 93 per cent of white people over 50 had been vaccinated but only 64 per cent of black people in the same age group. There may be many explanations for this, including inequitable access, but trust – or lack of it has been identified as the major factor.
What about Indigenous Australians? There is concern about vaccine hesitancy in this highly vulnerable group. In relation to other vaccines, they are known to have a higher uptake than non-Indigenous Australians, but a study in January 2021 showed an increase in unwillingness to be vaccinated against COVID-19.
Aboriginal health services have learned from the experience of the Indigenous peoples of the US that the vaccine roll out must be community led. These peoples have the highest rate of vaccine acceptance of all Americans.
High levels of vaccine hesitancy are also observed among the elderly in European migrant communities in Australia, who rely on news services in their home country, that are often negative about vaccines, especially Astra Zeneca.
A 2020 study in Ireland and the United Kingdom led by psychological researcher Jamie Murphy showed that the vaccine resistant or hesitant group was generally: more self-interested, more distrusting of experts and authority figures such as scientists, health care professionals and the state, and more likely to hold strong religious beliefs, and conspiratorial and paranoid beliefs. The authors suggested that these people would be more receptive to pro-vaccination messages from non-traditional authority figures, whom they might trust. They noted studies that had documented the effectiveness of involving religious leaders in improving acceptance of other vaccines.
When the vaccines were in development, there was considerable discussion among evangelicals about the moral acceptability of receiving a vaccine that had been developed using foetal cell lines from an historical abortion, such as the Astra Zeneca, or tested on such lines, such as the Pfizer. However, the Gospel Coalition, a Christian online platform that is very conservative on the issue of abortion, published several articles arguing that using these vaccines does not imply complicity in abortion, and that while not ideal, their use was justified by the moral imperative to prevent disease and death and to protect the vulnerable. And many other evangelical writers appealed to love of neighbour as a reason to be vaccinated.
Nevertheless, the group least likely to be vaccinated against COVID-19, in the US in a February 2021 study was white evangelicals. Disappointingly, only 48 per cent of white evangelicals said they would consider the community health effects “a lot” when deciding to be vaccinated, compared with 60 to 70 per cent of Black Protestants, Catholics and unaffiliated Americans.
So is ethos less persuasive for white US evangelicals than for other groups? They do not seem to have heeded the message of their leaders to be vaccinated out of love for neighbour. But I think rather that they are divided in terms of which leaders and influencers they trust.
In March this year, evangelical radio host Eric Metaxas tweeted “Don’t get the vaccine… Pass it on”. Some pastors have been accused of spreading conspiracy theories, including that the coronavirus is not real and that the vaccine is the mark of the beast. Among white evangelicals, vaccination resistance is largely shaped by political and cultural rather than religious beliefs. While some say that getting vaccinated demonstrates a lack of faith and giving in to fear, more significant factors are mistrust of government and an anti-science attitude that began with debates about evolution. Political differences are also important: the majority of white evangelicals are Republican, and Democrats were much more likely than Republicans to say they would be or have already been vaccinated against COVID-19.
An Australian survey in February 2021 also showed that vaccine hesitancy was higher in those who identified with the political right than those identifying with the centre and those on the left. Immunisation researcher Professor Julie Leask suggested that leaders and influencers from the political right needed to demonstrate publicly a strong commitment to vaccination. This might counter any antivaccination messages from other prominent rightwing politicians.
Among Australian Christians, vaccine resistance or hesitancy seems to be linked, as in the US, more to political and cultural than theological factors. And trusted Christian leaders may influence this significantly.
Rational arguments for COVID-19 vaccination based on evidence are not universally persuasive. People are also persuaded to be vaccinated or not by fear. And trust or mistrust in the person or group presenting the facts and the arguments determines to a great extent whether those facts are believed and the arguments are persuasive.
Those responsible for the vaccine rollout should pay attention to the credibility of the messengers they use in the various groups of Australians they wish to attempt to persuade to be vaccinated.
At a personal level when talking to friends or family who are hesitant about COVID-19 vaccination, being slow to speak and quick to listen, genuinely trying to understand people’s fears, demonstrating warmth, empathy, and the Christian virtues of patience, gentleness and humility, will likely be much more persuasive than simply restating medical facts and arguments. It will be certainly more persuasive than name calling or ridicule.
Dr Denise Cooper-Clarke is a medical ethicist, voluntary researcher with Ethos Centre for Christianity and Society and a member of the Social Responsibilities Committee.
This article, a shortened version of a paper given at the recent Evangelical Women in Academia Conference at Ridley College, will also shortly be published in the October edition of Equip magazine, published by Ethos.
“Since vaccination rates affect the whole of … the global community, it is not simply a question of ‘What is best medically for me?’ but ‘What ought I to do?’”