children. This foundation also may stimulate parents’ protective
instincts regarding vaccination and disease. The Fairness foundation
may fuel outrage in response to the perception that pharmaceutical
companies motivated by profit have an unfair voice in vaccine
policy. These two foundations also may be linked with concerns
among individuals with provaccine attitudes that unvaccinated
children put others (particularly those who cannot be vaccinated
for medical reasons) at risk.
Approaches to overcome objections
What all this means is that our approach to the antivaccine
movement cannot be monochrome. The underpinnings for people
allying with the antivaccine movement are quite varied. At the
point of care, how we respond to a vaccine-hesitant patient or
parent of a patient must be determined by the moral foundations
with which they most align. Explaining the public health benefits
of a well-vaccinated population is unlikely to move a person who
is highly aligned with the Liberty foundation. Providing a message
that reinforces taking control of your health, and explains how
vaccinations help you and others be free to live a happy and healthy
life is more likely to be effective for such a person.
The response to the larger antivaccine movement from a public
policy viewpoint likely will be influenced by the increasingly
frequent outbreaks of preventable diseases, such as measles, which
is occurring in the Dallas-Fort Worth area and in other parts of the
state. As of this writing, legislators have filed several bills relating
to vaccines. SB 329 by Sen. Ken Seliger (R- Amarillo) would
make school vaccine exemption rates available down to the level
of individual campuses, without identifying the immunization
status of each student, just as they exist at the district level.
At the other end of the spectrum, Rep. Matt Krause (R-Fort
Worth) has filed HB 1490, which would streamline the vaccine
exemption application process and prohibit the Texas Department
of State Health Services from tracking the number of exemptions
altogether.
How much this impacts the well-founded fear of these diseases
may determine our way forward. But all of this has happened
before, and it likely will happen again …. DMJ
March 2019 Dallas Medical Journal 9
interact with and grant legitimacy to modern institutions,
such as courts of law and police departments, bosses at work
and leaders of many kinds, including physicians. Traits such
as obedience and deference that are considered virtues in some
cultures — such as social conservatives — may be viewed as
vices in others — such as social liberals.
• The Fairness foundation is involved in acts of cheating or
cooperation among people or objects with which we interact.
Traits that people identify with in this foundation include
justice and trustworthiness. Triggers for the fairness foundation
are deception, infidelity or a broken vending machine that just
took your money.
• The Harm foundation is activated by visual and auditory
signs of suffering, distress or neediness. Terms such as “kind”
and “cruel” are used to describe people who care for or harm
those who are vulnerable. The harm foundation is triggered by
interactions with one’s own children, other children, stuffed
animals, and cartoon characters that are crafted to have the
proportions of children as well as stories of suffering of people
far away.
• The Loyalty foundation is activated by like-minded coalitions,
groups or tribes. Sports fandom and brand loyalty are examples
of how modern culture builds upon this foundation. Triggers
for this foundation include rage at traitors of the shared group
membership, patriotism and self-sacrifice for the group.
• The Purity foundation is activated by disgust at what is
perceived to corrupt the homeostasis of one’s body or larger
existence. Relevant virtues for this foundation are temperance,
piety and cleanliness. Triggers for this foundation are waste
products, contaminants, diseased people, and people who
are perceived as unlike us (immigrants or sexually nonbinary
people, for some individuals).
• The Liberty foundation involves reaction and resentment that
people feel toward those who dominate them and restrict their
liberty. It often is at odds with the Authority foundation and
includes the virtues of freedom and autonomy. Bullying and
being constrained by others are triggers for this foundation.
Research on the attitudes of vaccine-hesitant and vaccinerefusing
parents and on frequent claims of antivaccination websites
provides reason to suspect that some of the six moral foundations
might relate to vaccine hesitancy. A common opinion is that
vaccines are unnatural, and exposing children to diseases “naturally”
to build up immunity is preferable. Antivaccination websites also
often claim that vaccines contain “contaminants.” These concerns
may be rooted in the Purity foundation, with its emphasis on
avoiding anything disgusting or unnatural. Another frequent
message on antivaccine websites is that mandatory vaccination
policies violate parental civil liberties. The Liberty foundation may
be associated with such concerns about vaccine policy. Distrust of
scientists and government officials who promote vaccinations also is
common among people with unfavorable vaccine attitudes and on
antivaccination websites. This distrust may be associated with low
alignment with the Authority foundation and its associated respect
for and obedience to authority, or possibly high alignment with the
Liberty foundation and its resentment of perceived oppressors.
Other relationships between moral foundations and vaccine
hesitancy are plausible. The Harm foundation may underlie vaccine
hesitancy to the extent that people are concerned about the harm
that might result from vaccines, particularly if it affects vulnerable
Jason Terk, MD, is a Distinguished
Consultant with Cook Children’s
Physician Network and practices in
Keller. He is a passionate advocate
for vaccines and chairs the TMA
Council on Legislation. He also
advocates for vaccines through
the TMA Foundation’s “Be Wise,
Immunize” program. He is past
president of the Texas Pediatric
Society and serves on its Executive
Legislative Committee and
Committee on Infectious Diseases and Immunizations. He also
serves on the American Academy of Pediatrics Committee on
Federal Government Affairs.
Dr. Terk recently led a program at Cook Children’s to
improve the provision of the human papillomavirus vaccine
to eligible teens by working with physicians on effective
communication strategies. JasonV.Terk@cookchildrens.org
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