Vaccination Avoidance as Risk Avoidance Driven by Fear and Helplessness

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COMMENTARY

As the most recent wave of COVID-19 recedes, we can begin to learn from the example of vaccine avoidance how to help frightened, grieving, and misinformed patients who are vulnerable to hyperfocus on rare risks as a form of helplessness avoidance. Integrating specialty expertise via conversation—for example, between infectious disease specialists and psychodynamically informed psychiatrists—can help vulnerable patients become immunized against vaccine avoidance driven by fear and helplessness. Integrating expertise across specialties can also help us communicate effectively when participating in media-enabled public health education.

For example, the widespread alarm over news about the occurrence of blood clots in a tiny percentage of individuals who have received the Johnson & Johnson COVID-19 vaccine¹ provides a useful, if troubling, lesson about how wishful thinking undermines rational choice. Wishful thinking, including magical thinking such as perfectionism compounded by hindsight and our understandable wish for certainty to avoid mortal danger at any cost, has created unintended mortal risks of its own.²

It is wishful thinking to insist that any medical remedy be free of side effects or a “magic bullet” with 100% effectiveness. In clinical practice, we regularly inform patients of substantial side effects, the benefit/risk ratios, and available alternative treatments. When new data emerge, the benefit/risk ratio may change, and patients should be so informed. That is very different from the government’s pause of the use of the Johnson & Johnson vaccine for patients of all ages, irrespective of their vulnerability to side effects, the potential benefits, and what alternatives were practically available. This blanket measure, intended to reassure the public, had the opposite effect. A “where there is smoke, there is fire” response cascaded through the Internet and clouded both the benefit/risk ratio for the Johnson & Johnson vaccine and its efficacy relative to the other available vaccines in preventing COVID-19 morbidity and mortality. This is in the United States, where approximately a million people have died of COVID-19 in a population of 330 million,³ a death rate of about 1 in 330 (the risk for any individual varies by age and other factors).

Rationally, we should welcome any vaccine that dramatically reduces this risk. Yet in fast-moving cyberspace, our tunnel-vision focus on a newly reported, frightening yet isolated cluster of cases is likely to outrun daily reports of the all too familiar, and thus normalized, larger number of no less tragic deaths from COVID-19. Contrast this reaction with risk levels that individuals ordinarily accept, such as having children in the face of the—alas—still present risk of maternal mortality.⁴

This situation has many other analogues in medicine. For instance, some of us, when we are patients, worry about Guillain-Barré syndrome after influenza immunization, even though the risk of Guillain-Barré is much higher after infection with influenza than after immunization.⁵ Ideally, such comparisons of risks and benefits should be simple and straightforward to make. Why, then, when it comes to threats to our health, are they not? When we are frightened that our survival is somehow at stake, powerful feelings distort our reasoning to avoid feeling helpless.

When we feel in danger, we simplify. We tend to pay more attention to information that is recent or more readily available. The newly reported risk of a tragic yet rare side effect potentially related to vaccination all too often obscures the greater risks, both long- and short-term, of the ravages of the COVID-19 pandemic. Once we fixate on what is new and potentially dangerous, it tends to remain on our mental radar screen, regardless of data to the contrary. Moreover, individuals can all too easily avoid potential risks of vaccination by not being vaccinated, whereas even with masks and other precautions, we feel far greater helplessness relative to avoiding the risks of COVID-19. To avoid feeling helpless, it is easier and thus all too convenient to focus on easily avoidable yet low vaccination risks than on the far less easily avoidable yet high COVID-19 risks. In addition, we tend to feel greater shame when we do something that turns out badly than when we do not do something and it turns out badly. Thus, deaths due to inaction (not getting vaccinated) seem less frightening than deaths due to action (getting vaccinated).

Especially in the midst of fear and tragedy, we want to avoid helplessness at any cost, which makes us susceptible to wishful thinking and fantasies of omnipotence and the perfection of 20-20 hindsight. That susceptibility is compounded by internet transmission of misinformation and fear-mongering. It is no news that bad news beats good news in the marketplace of attention. Moreover, misleading reductionism typically carries the day (the curse of the sound bite). Now, on the small screens of mobile phones, we too often read the screaming headlines without getting to potentially reassuring qualifiers in the body of an article. Asking avoidant patients what information they have, where they get their information, and what it means to them is vital. In the same vein, asking about any individual or family history of adverse interactions with medications or the medical system may be helpful.

To be effective, public education about risk assessment must recognize this emotional component of our mental functioning. For the informed consent process of vaccination to be meaningful and effective, it helps to recognize the way fear in the midst of a pandemic intoxicates sober cognition with perfectionism and magical thinking. Therefore, when we communicate about newly emergent questions as to vaccination-related side effects, it will also help to keep in mind that our own public and social media communication may have side effects far greater than the vaccine side effects we seek to reduce.

Dr Bittner is a faculty member at Creighton University School of Medicine, and an infectious diseases physician who practices in Omaha, Nebraska, locale of one of the first cases of the suspected Johnson & Johnson COVID-19 vaccine-related blood clots. Dr Bursztajn is a faculty member at Harvard Medical School, and a practicing psychiatrist in Cambridge, Massachusetts, with a longstanding interest in decision-making under conditions of trauma and uncertainty.

References

1.Oliver SE, Wallace M, See I, et al. Use of the Janssen (Johnson & Johnson) COVID-19 vaccine: updated interim recommendations from the Advisory Committee on Immunization Practices - United States, December 2021. MMWR Morb Mortal Wkly Rep. 2022;71(3):90-95.

2. Bursztajn HJ, Feinbloom RI, Hamm RM, Brodsky A. Medical Choices, Medical Chances: How Patients, Families, and Physicians Can Cope With Uncertainty. Routledge; 1990.

3. Coronavirus in the U.S.: Latest map and case count. New York Times. Accessed March 4, 2022.

4. Hoyert DL. Maternal mortality rates in the United States, 2020. NCHS Health E-Stats. 2022. Accessed March 4, 2022.

5. Vellozzi C, Iqbal S, Broder K. Guillain-Barre syndrome, influenza, and influenza vaccination: the epidemiologic evidence.Clin Infect Dis. 2014;58(8):1149-1155.