Arguing About Vaccines Doesn’t Usually Work — But This Might

A doctor cradles a newborn who is sick with measles.

(© andriano_cz/Adobe)


Ethan Lindenberger, the Ohio teenager who sought out vaccinations after he was denied them as a child, recently testified before Congress about why his parents became anti-vaxxers. The trouble, he believes, stems from the pervasiveness of misinformation online.

There is evidence that 'educating' people with facts about the benefits of vaccination may not be effective.

"For my mother, her love and affection and care as a parent was used to push an agenda to create a false distress," he told the Senate Committee. His mother read posts on social media saying vaccines are dangerous, and that was enough to persuade her against them.

His story is an example of how widespread and harmful the current discourse on vaccinations is—and more importantly—how traditional strategies to convince people about the merits of vaccination have largely failed.

As responsible members of society, all of us have implicitly signed on to what ethicists call the "Social Contract" -- we agree to abide by certain moral and political rules of behavior. This is what our societal values, norms, and often governments are based upon. However, with the unprecedented rise of social media, alternative facts, and fake news, it is evident that our understanding—and application—of the social contract must also evolve.

Nowhere is this breakdown of societal norms more visible than in the failure to contain the spread of vaccine-preventable diseases like measles. What started off as unexplained episodes in New York City last October, mostly in communities that are under-vaccinated, has exploded into a national epidemic: 880 cases of measles across 24 states in 2019, according to the CDC (as of May 17, 2019). In fact, the Unites States is only eight months away from losing its "measles free" status, joining Venezuela as the second country out of North and South America with that status.

The U.S. is not the only country facing this growing problem. Such constant and perilous reemergence of measles and other vaccine-preventable diseases in various parts of the world raises doubts about the efficacy of current vaccination policies. In addition to the loss of valuable life, these outbreaks lead to loss of millions of dollars in unnecessary expenditure of scarce healthcare resources. While we may be living through an age of information, we are also navigating an era whose hallmark is a massive onslaught on truth.

There is ample evidence on how these outbreaks start: low-vaccination rates. At the same time, there is evidence that 'educating' people with facts about the benefits of vaccination may not be effective. Indeed, human reasoning has a limit, and facts alone rarely change a person's opinion. In a fascinating report by researchers from the University of Pennsylvania, a small experiment revealed how "behavioral nudges" could inform policy decisions around vaccination.

In the reported experiment, the vaccination rate for employees of a company increased by 1.5 percent when they were prompted to name the date when they planned to get their flu shot. In the same experiment, when employees were prompted to name both a date and a time for their planned flu shot, vaccination rate increased by 4 percent.

A randomized trial revealed the subtle power of "announcements" – direct, brief, assertive statements by physicians that assumed parents were ready to vaccinate their children.

This experiment is a part of an emerging field of behavioral economics—a scientific undertaking that uses insights from psychology to understand human decision-making. The field was born from a humbling realization that humans probably do not possess an unlimited capacity for processing information. Work in this field could inform how we can formulate vaccination policy that is effective, conserves healthcare resources, and is applicable to current societal norms.

Take, for instance, the case of Human Papilloma Virus (HPV) that can cause several types of cancers in both men and women. Research into the quality of physician communication has repeatedly revealed how lukewarm recommendations for HPV vaccination by primary care physicians likely contributes to under-immunization of eligible adolescents and can cause confusion for parents.

A randomized trial revealed the subtle power of "announcements" – direct, brief, assertive statements by physicians that assumed parents were ready to vaccinate their children. These announcements increased vaccination rates by 5.4 percent. Lengthy, open-ended dialogues demonstrated no benefit in vaccination rates. It seems that uncertainty from the physician translates to unwillingness from a parent.

Choice architecture is another compelling concept. The premise is simple: We hardly make any of our decisions in vacuum; the environment in which these decisions are made has an influence. If health systems were designed with these insights in mind, people would be more likely to make better choices—without being forced.

This theory, proposed by Richard Thaler, who won the 2017 Nobel Prize in Economics, was put to the test by physicians at the University of Pennsylvania. In their study, flu vaccination rates at primary care practices increased by 9.5 percent all because the staff implemented "active choice intervention" in their electronic health records—a prompt that nudged doctors and nurses to ask patients if they'd gotten the vaccine yet. This study illustrated how an intervention as simple as a reminder can save lives.

To be sure, some bioethicists do worry about implementing these policies. Are behavioral nudges akin to increased scrutiny or a burden for the disadvantaged? For example, would incentives to quit smoking unfairly target the poor, who are more likely to receive criticism for bad choices?

The measles outbreak is a sober reminder of how devastating it can be when the social contract breaks down.

While this is a valid concern, behavioral economics offers one of the only ethical solutions to increasing vaccination rates by addressing the most critical—and often legal—challenge to universal vaccinations: mandates. Choice architecture and other interventions encourage and inform a choice, allowing an individual to retain his or her right to refuse unwanted treatment. This distinction is especially important, as evidence suggests that people who refuse vaccinations often do so as a result of cognitive biases – systematic errors in thinking resulting from emotional attachment or a lack of information.

For instance, people are prone to "confirmation bias," or a tendency to selectively believe in information that confirms their preexisting theories, rather than the available evidence. At the same time, people do not like mandates. In such situations, choice architecture provides a useful option: people are nudged to make the right choice via the design of health delivery systems, without needing policies that rely on force.

The measles outbreak is a sober reminder of how devastating it can be when the social contract breaks down and people fall prey to misinformation. But all is not lost. As we fight a larger societal battle against alternative facts, we now have another option in the trenches to subtly encourage people to make better choices.

Using insights from research in decision-making, we can all contribute meaningfully in controversial conversations with family, friends, neighbors, colleagues, and our representatives — and push for policies that protect those we care about. A little more than a hundred years ago, thousands of lives were routinely lost to preventive illnesses. We've come too far to let ignorance destroy us now.

Junaid Nabi
Junaid Nabi, MD, MPH, is a physician, public health researcher, and a medical journalist. He currently manages several research projects at Brigham Health that include investigating provider- and hospital-level factors associated with racial and ethnic disparities in surgical oncology; evaluating the fiscal impact of consolidating care of complex patients; and, examining systematic factors that lead to opioid over-prescribing patterns after surgery. He has also undertaken research that examined the effect of health disparities that arise from social and political disenfranchisement and the relationship between trauma care and post-traumatic stress disorder (PTSD). Previously, he was a Fellow in Bioethics at Harvard Medical School Center for Bioethics where he studied bioethical issues in global healthcare delivery; role of bioethicists in Artificial Intelligence, Machine Learning, and other evolving technologies; and, emotional intelligence in bioethical analysis. He is a New Voices Fellow at The Aspen Institute, Washington, D.C., and a Fellow at Harvard Graduate School Leadership Institute, Boston.
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