Tuesday, 18 September 2018

Vaccine Hesitancy and Trust

This post is by Elisabetta Lalumera (University of Bicocca, Milan). In this post she summarises a paper forthcoming in Rivista di Estetica, entitled: "Trust in healthcare systems and vaccine hesitancy."

Healthcare systems can positively influence our personal decision-making and health-related behavior only if we trust them. What does it take for the public to trust a healthcare system? I propose that the trust relation is based on an epistemic component, epistemic authority, and on a value component, the benevolence of the healthcare system. I argue that it is also affected by the vulnerability of the pubblic on healthcare matters, and by the system’s credibility.

My proposed analysis of public trust in health care systems can be used to better understand the phenomenon of vaccine hesitancy, the tendency to question vaccine policies, and to seek alternative vaccine schedules or refuse vaccination.


Trust in health care is a three-place relation, involving an institution (a community’s health care system), a collective entity (the public), and a field of application, which is what the public trusts a health care system for. The public is the varied group of consumers, seekers and providers of health to which a health care system addresses its services, which in national health care systems virtually coincides with the whole population. Examples of fields of application are information (about, for example, the risks of smoking), prevention (as in immunization campaigns, and screening tests), diagnosis, therapy, hospitalization, but also organ and blood donation.

Public trust in health care involves vulnerability in two respects: (1) we trust someone because we cannot personally take care of all our material and immaterial goods and in particular, we trust an institution because we are unable to manage some area of our life by ourselves, as individuals; (2) we trust healthcare systems with our personal health, and the health of our families and our communities. 

When is it appropriate to trust? First, public trust in health care is grounded on the epistemic authority of health care practitioners, and of the system collectively taken. We can’t expect the health care system to promote, maintain or restore our health unless we assume that it embodies sufficient knowledge, competence, and skills to do so. Second, public trust in health care depends on the confidence that healthcare practitioners will act on the knowledge, competence and skills they possess in order to promote, maintain or restore our health, and not with other goals in view.

Though normatively public trust is founded on epistemic authority and value sharing, in fact it correlates with the credibility of the trusted part. Credibility in this context is the capacity to produce in others the impression that one is epistemically authoritative and benevolent. The public is willing to grant trust if the health care system is credible enough.

Vaccine hesitancy

How does this notion of trust apply to the case of vaccine hesitancy? Vaccine hesitancy is the tendency to refuse children vaccination or to adhere to alternative vaccination schedules, despite availability of vaccination opportunities. Vaccine hesitancy is a health care priority, because it threatens herd immunity, and puts the lives of the more vulnerable (elderly or immuno-depressed patients) at risk. I believe that its features qualify it a case of public distrust - or of decline in trust - towards health care systems, that can be explained by employing the conceptual points of the model I proposed above.

The alleged association between vaccination and autism remains a reason for vaccine hesitancy despite the publication and public dissemination of studies that disconfirm the hypothesis or show the small incidence of adverse effects after vaccination. As there is evidence of high levels of education of a significant segment of the vaccine-resistant public, the problem is not that the public lacks information or understanding, but that it challenges both the epistemic authority and the good will of health care systems.

Moreover, vaccination brings some small amount of immediate harm, especially to a child, e.g. redness, swelling or pain at the injection site, and other minor side effects. Like any medical treatment, it carries no-zero risk of serious side effects. In the light of this, some parents prioritize their own (or their own children’s) immediate or short-term interest (receiving no harm) over the interest of the community in achieving herd immunity and protecting weaker groups.

The credibility of health care systems is paramount in the vaccine hesitancy case. The phenomenon involves the attribution of negative values (corruption, absence of transparency) to health researchers and health authorities for their relationship with Pharma companies that produce and sell vaccines. Attribution of negative values undermines the grounds of public trust, and it additionally diminishes credibility. As a result, the evidence provided on vaccine safety is dismissed from the start as tainted.

One conclusion that could be drawn from this is that to tackle vaccine hesitancy as a medical emergency we should focus on restoring trust.

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