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Moral Intuitions About Stigmatizing Practices and Feeding Stigmatizing Practices: How Haidt’s Moral Foundations Theory Relates to Infectious Disease Stigma

Moral Intuitions About Stigmatizing Practices and Feeding Stigmatizing Practices: How Haidt’s... Public HealtH etHics VOluMe 16 • issue 1 • 2023 • 102–111 102 Moral intuitions About s tigmatizing Practices and Feeding s tigmatizing Practices: How Haidt’s Moral Foundations t heory Relates to infectious Disease s tigma C. (Carlijn) Damsté Faculty of Humanities, Utrecht University, The Netherlands K. (Koen) Kramer, Faculty of Veterinary Medicine, Department of Population Health Sciences, Animals in Science and Society, Utrecht University, The Netherlands *Corresponding author: C. (Carlijn) Damsté, Utrecht University, Faculty of Humanities, The Netherlands, Email: carlijndamste@hotmail.com Despite extensive stigma mitigation efforts, infectious disease stigma remains common. So far, little attention has been paid to the moral psychology of stigmatizing practices (i.e. beliefs, attitudes, actions) rather than the experience of being stigmatized. Addressing the moral psychology behind stigmatizing practices seems nec- essary to explain the persistence of infectious disease stigma and to develop effective mitigation strategies. Our article proposes building on Jonathan Haidt’s moral foundations theory, which states that moral judge- ments follow from intuitions rather than conscious reasoning. Conceptual analysis was conducted to show how Haidt’s five moral foundations can be connected to (i) moral judgements about stigmatizing practices and (ii) stigmatizing practices themselves. We found that care/harm, fairness/cheating, loyalty/betrayal and sanctity/ degradation intuitions can inform moral judgements about stigmatizing practices. Loyalty/betrayal and sanc- tity/degradation intuitions can sometimes also feed stigmatizing practices. Authority/subversion intuitions can inform moral judgements and stigmatizing practices towards people who disrespect authoritative rules meant to protect public health. Moral dumbfounding and posthoc reasoning might explain the persistence of stigma- tizing practices. In conclusion, this study demonstrates the relevance of Haidt’s approach to infectious disease stigma research and mitigation strategies. We hope that this study motivates researchers to further test and assess this approach. e s Th tigma concept has been extensively investigated introduction by various scholars, especially within psychology and Stigma related to infectious diseases, henceforth called sociology (Goffman, 1963; Link & Phelan, 2001). Link ‘infectious disease stigma’, negatively ae ff cts many peo- and Phelan have influentially construed stigma as a phe- ple (Fischer et al., 2019). In the past, outbreaks of, for nomenon rooted in social interaction, defining it as ‘the example the plague, cholera, measles and yellow fever co-occurrence of (...) labeling, stereotyping, separation, led communities to marginalize people who were status loss, and discrimination’ and further indicating infected or thought to be infected (Kraut, 1998; Perry & that ‘for stigmatization to occur, power must be exer- Donini-Lenho, 2010 ff ). HIV-related stigma is the most cised’ (Link & Phelan, 2001: 363). Labeling relates to the well-documented infectious disease stigma in contem- social selection of a classification that is ‘affixed’ to a per - porary society (Avert, 2019), but stigmatization has also son or group, such as gender or skin color or having an occurred in relation to Covid-19 (Bhanot et al., 2020). infectious disease. These labels can be linked to a group In spite of extensive mitigation efforts, for example of undesirable characteristics leading to development through educational and awareness campaigns, infec- of stereotypes. Labeled persons can be placed in dis- tious disease stigma remains common. tinct groups, as a way to separate ‘us’ from ‘them’. When https://doi.org/10.1093/phe/phad002 Online publication date: 21 March 2023 © The Author(s) 2023. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. MORal iNtuitiONs aND stiGM atiZiNG PR actices • 103 labeling and stereotyping occur, an associated result is for policies and research targeting infectious disease general downgrading of those persons, also called status stigma. loss. Discrimination is the unfair or unjust treatment of Investigating how people respond to harmless taboo labeled persons. The role of power in stigma is some- violations (see box 1), Haidt and colleagues have con- times very clear, whereas it can also be easily overlooked cluded that moral judgments typically follow from fast ‘because in many instances power differences are so and unreflective cognitive processes, while conscious taken for granted as to seem unproblematic’ (Link & moral reasoning mainly takes place aer a m ft oral judge- Phelan, 2001: 375). ment is made, also called posthoc reasoning (Nisbett & Scholars have also come to understand stigma as a Wilson, 1977; Kunda, 1990; Kuhn, 1991; Perkins et al., category of moral interaction and experience. Yang et al. 1991; Haidt, 2001). People oen s ft truggle or fail to sup- argued that the notion of stigma is an essentially moral port their intuitive judgment regarding harmless taboo issue, as people who are stigmatized experience threats stories through conscious reasoning, but will maintain to morally relevant interests (Yang et al., 2007). They their judgment nonetheless—this is phenomenon is argued that adding moral experience to the concept of called moral dumbfounding (Björklund et al., 2000). stigma would provide new insights in understanding the Haidt and colleagues have identified five moral founda - behaviors of those involved, because this allows investi- tions or types of intuitions on which moral judgments gation of ‘what matters most’ to people who are being are based. First, care/harm intuitions ‘makes us sensi- stigmatized (Yang et al., 2007). tive to signs of suffering and need’, while ‘it makes us This article, by contrast, concerns the moral psy- eschew cruelty’ (Haidt, 2012: 178). Second, intuitions chology of stigmatizing practices rather than the of the fairness/cheating foundation make us ‘sensitive experience of being stigmatized. According to Stangl to indications that another person is likely to be a good et al., stigmatizing practices concern beliefs, attitudes (or bad) partner for collaboration and reciprocal altru- and actions, whereas stigma experiences include lived ism’ (Haidt, 2012: 178). Third, loyalty/betrayal intu- experiences (Stangl et al., 2019: 2). Practices relate to itions make us ‘sensitive to signs that another person people who stigmatize and experiences relate to peo- is (or is not) a team player’ (Haidt, 2012: 178). Fourth, ple who are being stigmatized. Addressing the moral intuitions of the authority/subversion foundation make psychology behind stigmatizing practices seems nec- us ‘sensitive to signs of rank or status, and to signs that essary to explain the persistence of infectious disease other people are (or are not) behaving properly, given stigma, and will presumably yield important lessons for their position’ (Haidt, 2012: 179). Last, the sanctity/ mitigation strategies. Our article proposes building on degradation foundation involve intuitions that are Jonathan Haidt’s work to investigate the moral psychol- evolved to protect oneself against pathogens and para- ogy of stigmatizing practices, as a promising new route sites, which ‘makes it easy for us to regard some things box 1 – Harmless taboo violations In one of his most famous investigations, Haidt asked people for responses to short stories (Haidt, 2001). These stories, which were called harmless taboo violations, describe actions that many people find oen ff sive but that do not harm anyone. An example of such a story is about Julie and Mark (see below). Aer h ft earing this story, most people immediately say that it was wrong for Julie and Mark to make love. en, Th aer ft giving their judgement, they start searching for reasons (Haidt, 2001). Haidt calls this post hoc reasoning. This happened for the story of Julie and Mark, but also for many other harmless taboo violations stories integrating with Haidt’s proposed moral foundations. From Haidt (2001), this is the story of Julie and Mark: “Julie and Mark are brother and sister. They are traveling together in France on summer vacation from college. One night they are staying alone in a cabin near the beach. They decide that it would be interesting and fun if they tried making love. At the very least it would be a new experience for each of them. Julie was already taking birth control pills, but Mark uses a condom too, just to be safe. They both enjoy making love, but they decide not to do it again. They keep that night as a special secret, which makes them feel even closer to each other. What do you think about that? Was it OK for them to make love?” (p. 814) 104 • Da MstÉ aND KR a MeR as “untouchable”, both in a bad way (because something Second, we have illustrated our analysis with exam- is so dirty or polluted we want to stay away) and in a ples from previous pilot research (Damsté & Kramer, good way (because something is so hallowed, so sacred, 2021), in which we asked seven interviewees to respond that we want to protect it from desecration)’ (Haidt, to six constructed stories that resembled Haidt’s harm- 2012: 173, 179). The sanctity/degradation foundation is less taboo violations but explicitly addressed HIV and also referred to as the ‘purity construct’ (Shweder et al., the Covid-19 stigmatization (see Supplementary mate- 1997). rial 1). The analogy between Haidt and our constructed In this article, we propose that stigmatizing prac- stories was that both concerned morally salient actions tices in relation to infectious diseases and moral judg- but excluded ex hypothesi that those actions would harm ments about such stigmatizing practices may well be anyone. This way, both types of stories help to explore influenced by the same cognitive process and moral a broader spectrum of moral intuitions than care/harm foundations that Haidt and colleagues have identified. intuitions only. The limitations of this earlier study can- As stigmatizing practices include subjective states not be overstated and we do not make any empirical related to judgements, such as beliefs and attitudes claims on how intuitions are based on the five founda- (Stangl et al., 2019), and as Haidt argues that moral tions inform stigmatizing practices. The fragments we judgements are primarily based on intuitions (Haidt, have drawn from the interviews merely serve to illustrate 2001, 2012), it makes sense to expect that both are how Haidt’s five moral foundations can sometimes be related. We show how Haidt’s five moral foundations recognized in peoples’ conversations regarding stigma can be conceptually connected to moral judgements and infectious diseases. We hope that this will motivate about stigmatizing practices regarding infectious dis- adequately resourced researchers to build on Haidt’s eases and to such stigmatizing practices themselves. work to study infectious disease stigma empirically. We enrich this conceptual analysis with examples For our earlier study, a posthoc ethical approval was from our previous work (Damsté & Kramer, 2021), in given by the Faculty Ethics assessment Committee of the which we asked seven people to respond to our con- Faculty of Humanities (reference number: 22-161-01). structed stories that resembled Haidt’s harmless taboo e s Th tudy did not pose any credible physical, psycho- violations but explicitly addressed infectious diseases logical, social or economic risks to our interviewees and and stigmatization. We thus argue that moral intu- data management and informed consent procedures itions can be expected to inform moral judgements met generally accepted standards. about stigmatizing practices, and sometimes even to feed those practices themselves, and illustrate how concepts from Haidt’s moral foundations theory may Findings: how Haidt’s moral apply in particular cases. foundations can be conceptually linked to moral judgements Methods about stigmatizing practices and stigmatizing practices themselves As a first step, we have mapped conceptual connections between infectious disease stigmatization on the one In this section, we demonstrate how Haidt’s moral foun- hand and Haidt’s five moral foundation on the other. dations can be conceptually linked to moral judgements This explorative desk research considered how the con- and stigmatizing practices in the context of infectious cepts defining each moral foundation (care/harm, fair - diseases. We elaborate on each foundation and close ness/cheating, loyalty/betrayal, authority/subversion, with the phenomenon of moral dumbfounding. Table sanctity/degradation) relate to concepts associated with 1 presents an overview of how the foundations can be infectious diseases and stigmatization. Our analysis conceptually linked to judging about stigmatizing prac- shows how the five foundations are a priori likely to (i) tices and stigmatizing practices themselves. inform moral judgements about stigmatizing practices To enrich this conceptual analysis and to illustrate related to infectious diseases, and to (ii) feed infectious the conceptual connection between Haidt’s foundations disease stigma. This helps to construct stories that can and stigmatizing practices, we show how different intu- be used (similarly to Haidt’s harmless taboo stories) to itions can be recognized in sample fragments from pilot trigger peoples’ moral intuitions with respect to this interviews. These fragments sometimes feature stigma- topic. tizing components, including labeling, stereotyping, MORal iNtuitiONs aND stiGM atiZiNG PR actices • 105 t able 1. Conceptual examples of intuitions that inform moral judgements about stigmatizing practices (i.e. beliefs, attitudes, actions) and intuitions that feed stigmatizing practices per moral foundation Moral foundation Examples that intuitions inform moral judgements Examples that intuitions feed stigmatiz- about stigmatizing practices ing practices Care/harm Not providing someone in need care, because she - has an infectious disease, is wrong Fairness/cheating Not hiring someone because of her infectious - disease, when she would pose no significant trans- mission risk to her colleagues, clients, or others, is unfair Loyalty/betrayal Not caring for people in your ingroup because they Members from one’s ingroup should have an infectious disease is disloyal; be protected from people that could Banishing an ingroup members that have an infec- transmit infectious diseases to them, by tious disease is wrongful shutting such people out of the ingroup Authority/subver- Not following up rules that authorities have estab- Someone who does not adhere to rules sion lished to protect public health, such as to repress an meant to protect public health and con- infectious disease pandemic, is wrong trol transmission of infectious diseases is labeled and discriminated for this Sanctity/degrada- Sticking of the label ‘dangerous because of potential Someone with an infectious disease is tion transmission’, in case when there is no transmission labeled as polluted, impure; risk, is unfair Not engaging in a (sexual) relationship because of the infectious disease, even if it cannot be transmitted anymore, just to be on the safe side Within this foundation, the trigger for (moral judgements about) stigmatizing practices is different compared with the other foundations: it is about non-adherence to authoritative rules related to infec- tious diseases, rather than to the infectious disease itself. separation, status loss and/or discrimination (Link & give help [bring food] if you can. Yes. If you know about that.” Phelan, 2001). An infectious disease is contagious and transmittable in nature, although under certain circumstances it can The Care/Harm Foundation also be untransmittable. If there is a transmission risk, e c Th are/harm foundation makes us sensitive to signs care/harm intuitions might weigh more heavily in moral of suffering and need, and the concepts of suffering judgements, as there is a potential harm to prevent to and need connect to infectious diseases in clear ways. others. But if there is no transmission risk, there is no Care/harm intuitions will presumably trigger feelings potential harm (i.e. transmitting or contracting the of care for someone who is (seriously) ill because of an infectious disease) to prevent, and one would expect infectious disease, or is perceived to suffer from some to see this reflected in intuitions and judgements about other type of harm due to the infection, including men- how to treat people carrying infections. (As explained tal stress due to stigmatization. It makes us share in the below, however, this expectation may well be frustrated pain of others and to wish to avoid harm for them. These by the persistence of sanctity/degradation intuitions.) intuitions can thus give rise to moral judgements that When there is a transmission risk, this foundation you should care for someone in need. ‘Need’ is a broad could well give rise to an urge to prevent further trans- concept and can vary from the need for care to the need mission of infectious diseases, given the potential harm for food, which the fragment below refers to: of transmission involved (of note: this can also be related to the loyalty/betrayal foundation, which is further dis- “If she is housebound at some point, due to the cussed below). If someone poses a transmission risk to [Covid-19] quarantine, then I think you should 106 • Da MstÉ aND KR a MeR another, this might evoke moral judgements about risky ‘bad collaborators’. It suppresses free riding (i.e. receiv- behavior and that this person does not care for others ing the benefits of cooperation without carrying the (i.e. does not prevent transmission) which is a wrong- costs). Someone who has an infectious disease but acts ful act. As care/harm intuitions are focused to care for carelessly (i.e. posing transmission risks), whereas oth- the other, rather than oneself, this foundation would not ers do act in a careful way toward this person, might be provoke judgements about an urge to protect oneself (of judged as a bad partner for collaboration. note: the urge to prevent transmission to oneself does “If he highly appreciated that his friend cancelled come back with sanctity/degradation intuitions, as dis- the appointment the previous time [due to hav- cussed below). ing Covid-19-related symptoms], then it seems to me that you should do the same. (…) If you did “I think that Tom just shouldn’t take that risk appreciate that your friend does so [cancelling [of visiting the birthday of his grandparents the appointment], but you yourself prefer your with Covid-19-related complaints], because own advantage and want to have fun, well, I don’t they just really… If he transmits something, think that’s a good thing.” then he will have to carry that burden for the rest of his life. I: in what way? R: well, I think Moreover, the fairness/cheating foundation might trig- that, if you, if you do something like that and it ger intuitions and moral judgements about unequal goes wrong, then it’s something which poses a rights, for example in case of not hiring someone on the heavy burden on you because you proved that, basis of an HIV-positive status, which seems unfair if you did harm to your grandparents, and per- hiring the applicant would not pose a significant health haps even caused their deaths. So that seems to me, seems clear to me that you just shouldn’t risk to her prospective colleagues, customers, etc. e Th take that risk.” example below shows that fairness/cheating intuitions inform moral judgements and create certain awareness However, in cases where there is no transmission risk, that stigma is involved (i.e. saying that it is discrimina- one would expect care/harm intuitions to be more tion to not hire someone with the label ‘having HIV’). focused on the already existing harm of having an This shows that fairness/cheating intuitions can inform infectious disease for others, and the associated feel- judgements about stigmatizing practices, even though ings of caring for or compassion for someone’s situa- these intuitions do not necessarily lead to those prac- tion. Someone who refrains from offering someone tices themselves. care because that person has an infectious disease may well be judged as acting wrongly on these grounds “My first feeling is that it [not hiring due to HIV] is simply not allowed at all, that it’s discrimina- (especially if providing care would not expose the tion. I: and what makes it discrimination? R: well, caregiver to significant (transmission) risks). Not it’s just like you won’t hire a women because of offering care can in such a case be considered a form her wish to have a child.” of discrimination, prompted by the person’s ‘label’ as someone having an infectious disease, and thus as a Another perspective is that fairness/cheating intuitions stigmatizing practice. This suggests that care/harm might contribute to being aware of structural forms of intuitions can inform moral judgements about stig- stigma. A similar case as argued by Henderson et al. on matizing practices, although they do not necessarily substance misuse could be made here (Henderson & feed stigmatizing practices themselves. Dressler, 2019): strong disapproval of inequality might result in recognition of structural processes that lead “If you can’t communicate at distance, it [caring to contracting infectious diseases (such as increased for someone with Covid-19] is more difficult I HIV risk among trafficked women (Yu et al., 2021) have to say, because then you would have to ring the bell, to really converse with each other, and I or increased Covid-19 risk among economically dis- don’t know if I would feel completely comfortable advantaged groups (Patel et al., 2020)), which could with that.” be associated with thinking that having an infectious disease is not fully a personal choice. In other words, not everyone has equal chances of contracting a certain The Fairness/Cheating Foundation infectious disease. These intuitions might thus make e fa Th irness/cheating foundation pertains to reciprocal people sensitive for signs of inequality in contracting altruism. It makes us want to punish cheaters, who do infectious diseases, which relates to being aware of not stand for mutual collaboration and who are thus structural stigma. MORal iNtuitiONs aND stiGM atiZiNG PR actices • 107 adhere to the Covid-19 rules and thereby show a lack of The Loyalty/Betrayal Foundation respect for authority. Stigmatization does not occur here Loyalty/betrayal intuitions can be expected to arise because the person stigmatized is (suspected of ) having when the infectious disease influences relationships. an infectious disease, but due to their (perceived) non- Next to the care/harm intuitions as discussed above, adherence to rules meant to protect public health and the urge to prevent further transmission of infectious to contain the transmission of infectious diseases. Such diseases might also be fed by loyalty/betrayal intu- behavior might trigger the authority/subversion founda- itions. As preventing transmission is a form of caring tion and can hence lead to dismissive moral intuitions. for another, one might say that preventing trans- es Th e intuitions might in turn motivate stigmatizing mission towards others of your ingroup (e.g. family, practices, for example labeling and stereotyping the friends) is part of loyalty within your relationships. person as a ‘wappie’ (a Dutch neologism from Covid-19 This suggests that loyalty/betrayal intuitions can be a times that roughly means ‘a weirdo who is out of touch motivation for stigmatizing practices toward people with reality’), which implies a loss of status and invites outside of one’s ingroup: the urge to loyally protect separation and discrimination. Although the trigger for friends and family can easily lead to separation from stigmatizing practices is different on this moral founda- people labeled as risky for one’s ingroup. In the early tion compared with the other foundations (namely, the Covid-19-pandemic times, for example households perception that someone subverts authoritative rules or small groups of friends agreed to only see each related to infectious disease control and public health other, to limit cross transmission and extra contacts protection rather than (the suspicion) that someone from outside, in order to create a ‘safe bubble’ with carriers an infectious disease), it can motivate stigmati- each other. Sometimes, this occurrence went so far zation in relation to infectious diseases. that people were labeled as ‘safe’ (e.g. the ones who strictly adhere to the Covid-19 rules) or ‘unsafe’ (e.g. The Sanctity/Degradation Foundation the ones who did see others and were loose with the Covid-19 rules)—and that preference was given to At last, the sanctity/degradation foundation can be only let in the ‘safe’ people within ones bubble. expected to trigger intuitions about infectious diseases Second, when you refrain from providing close rela- or people with an infectious disease, simply because of tives due care, this might be considered as an act of dis- the infectious nature or related characteristics of, e.g. loyalty. An extreme example of separation is banishment how such an infection is (assumed to be) contracted. of ingroup members such as friends or family, due to Having an infectious disease may be labeled as being a person’s infectious disease. Loyalty/betrayal intuitions ‘impure’ as it is something from outside interrupting the can help someone to recognize that such practices are sanctity of the body. When this foundation is triggered, stigmatizing and morally problematic. this is likely to result in negative judgements (Haidt, 2012). For example, if the infectious disease is obtained “You can’t blame her for what happened to her, through unsafe sex or unsafe needle use, this could trig- can you? I mean, if your child contracted a dis- ger judgements that these acts have desecrated the body. ease which, well… Then it’s simply just bad for On the other hand, if the infectious disease is obtained her. Then you should even love her more, so to speak, be extra concerned, especially in such through bad luck, this might not trigger this foundation. times close her in your arms, and not sending In addition, sanctity/degradation intuitions may away. Those are things I just cannot imagine.” make people want to stay away from people who are potential sources of infection, even when there is no In sum, loyalty/betrayal intuitions can inform moral actual transmission risk, just to be on the safe side. For judgements about stigmatizing practices toward people example, sanctity/degradation intuitions could explain in one’s ingroup. On the other hand, loyalty/betrayal why people might still feel unsure about entering into intuitions can probably lead to stigmatizing people who a sexual relationship with someone who has a positive are labeled as a risk to one’s ingroup. HIV-status but cannot transmit the virus because effec- tive treatment (Eisinger et al., 2019): The Authority/Subversion Foundation “I would not engage so quickly in a sexual contact e a Th uthority/subversion foundation concerns respect with a person who has HIV. But suppose it hap- for authority and status and will presumably trig- pens, sexual contact, I would just use condoms ger moral judgements about, e.g. people who do not then, even if there is perhaps no risk anymore, 108 • Da MstÉ aND KR a MeR but just to be sure. I: and why? Because you say, I might get sick. That I can get it [HIV]. Even would use it, even when the risk is not there any- though it is treatable and it is said that it cannot more, but to be sure. How does that work in your be transmitted anymore, but well you don’t know mind? R7: yes stupid, yes it’s a bit crazy actually. that. I: what don’t you know? R: that it is not (…) On the one hand I would say, do what makes transmittable. I: but that’s what I just said. R4: yes you feel good, and use condoms or don’t use it, [elongated yes], that’s what you say. [laughs] I: but whatever you feel comfortable with. On the other what is it then, why do you think this? R: well, I hand, I keep having a bit of a dirty feeling in my don’t know. It’s something of uncharted territory. mind then, that it might be transmitted one day. I: and what if that whole territory is known? R: Yes, it’s a bit of a crazy feeling what is in my mind yes, there is always a risk, everywhere is a risk. or something, can’t really explain it either.” See, when I get a little shot soon [Covid-19 vac- cine], then I can still get it, it isn’t 100% sure that Avoidance due to perceived transmission risks, while I can’t get it. Nothing can be ever ruled out with there are no such risks, might be judged as avoidance 100% certainty. So even if it is well treatable, then on wrong grounds. Examples might be not engaging in there is always a risk, always a chance, that you still can get it. I: and suppose, very hypothetically, a sexual relationship with someone with HIV but who it is not, there is no risk, there is no chance. R: is under effective treatment or keeping additional dis- well look, it never just goes wrong because of the tance while someone is already recovered from Covid- disease of course, but. I: what do you mean? R: 19 and cannot transmit anymore. e Th act in itself can be well, see, a relationship with someone is not only considered as a stigmatizing practice—the label of ‘dan- about a disease, it’s also about how the person is, if gerous because of potential transmission’ sticks unjusti- you can get along together, there are many things. fiably and leads to separation. This shows that sanctity/ I: and if that’s also all okay? R: yes why not? Yes. degradation intuitions can inform moral judgements But yes, that is, but yes. Well, in principle, then it about stigmatizing practices as well as underlie stigma- is, then it could be. I: and would you feel comfort- tizing practices. able with it, with such a relationship? R: [silence] I think so yes. Hypothetically speaking. [laughs] I: yes? R: well, you just say, if everything, if you Moral Dumbfounding and Post- can’t get it. Then nothing is wrong, right. I: okay, and you have to laugh now, does it really feel so? hoc Reasoning: When intuitive R: well, that’s so, if it really isn’t... But in my opin- Judgements and c onscious ion, there is always a bit of ambiguity, and I think that would always gnaw a bit.” Reasoning do not a gree and How t his Might Maintain s tigmatizing In this fragment, the respondent expresses doubts about engaging in a (sexual) relationship due to the risks Practices of transmission, and for the most part judges that it Moral dumbfounding occurs when people struggle or would be better not to have such a relationship. When fail to support their intuitive judgement but will main- the person gets access to rational arguments that HIV tain their judgement nonetheless (Björklund et al., 2000). is untransmittable due to effective treatment, extensive This might explain why people maintain to stigmatizing posthoc reasoning occurs, in which the respondent practices (i.e. beliefs, attitudes, actions), even when they seeks to support his judgment by oer ff ing reasons to have access to persuasive arguments that disprove their doubt the effectiveness of the antiviral treatment. This intuitive judgements leading to stigmatizing practices. suggests that the respondent’s judgment is based on e f Th ragment below exemplifies how dumbfounding sanctity/degradation intuitions rather than (only) care/ can occur within the context of infectious diseases and harm intuitions, but is rationalized in terms of harm. how it can feed stigmatizing practices. Although more Even when the respondent accepts (at least for the sake research is required and we do not intend to make any of argument) that there is no risk of transmission, the substantive claims here, we hope that other researchers judgment that it would be better to avoid having this will be motivated to explore this further. type of relationship does not fully disappear. This is arguably an example of moral dumbfounding, where “Yes that person then indicates that he has it an intuitive moral judgment is maintained (by persist- [HIV], yes God, what kind of risks does that ing sanctity/degradation intuitions) even though argu- entail, does it have impact on the health of for example me, or well, what is the risk that I ments for that judgment fail. The fragment provided in MORal iNtuitiONs aND stiGM atiZiNG PR actices • 109 the previous subsection (see page 13) provides another & Dressler, 2019: 16). This does not contradict our find- example of someone struggling to rationalize their intui- ing that fairness/cheating intuitions can inform moral tive judgement, and even self-consciously admitting that judgements about stigmatizing practices rather than they lack a ‘real’ explanation, without relinquishing that feed stigmatizing practices. judgment. Nevertheless, empirical investigation is needed first to assess our conceptual analysis and to further test the potential of our approach. It is necessary to draw firmer conclusions concerning the influence of moral intuitions Discussion on moral judgements and stigmatizing practices within To the best of our knowledge, this is the first study that the context of infectious diseases in order to make sub- examines whether and how Haidt’s theory on moral stantive claims about the full ability of this approach. intuitions can be conceptually linked to stigmatizing We hope that our conceptual analysis motivates ade- practices related to infectious diseases. We conducted quately resourced researchers to build on Haidt’s work desk research including a conceptual analysis. Our to empirically examine stigmatizing practices related findings showed that Haidt’s moral foundations, in the to infectious diseases. Such research can draw on our context of infectious diseases, can be conceptually con- conceptual analysis to construct additional stories nected to moral judgements about stigmatizing practices related to infectious disease stigma, which would give and sometimes to stigmatizing practices themselves. We more insight into the role of moral intuitions in stigma- enriched this conceptual analysis with examples from tizing practices in a wealth of situations. Within these previous work. It demonstrated the potential of applying further investigations, possible limitations of the moral Haidt’s moral foundations theory to infectious disease foundations theory should also be considered. One cri- stigma, and thereby oer ff s an innovative perspective tique is that the sanctity/degradation foundation is het- to respond to stigmatizing practices around infectious erogenous: it has been argued that the construct lacks diseases. a coherent understanding (Gray et al., 2022). Others Our analysis suggest that care/harm, fairness/cheat- have questioned Haidt’s theory for (more or less com- ing, loyalty/betrayal, and sanctity/degradation intuitions pletely) rejecting the role of rational reasoning in moral indeed have the potential to inform moral judgements judgement formation, rather than acknowledging the about stigmatizing practices regarding infectious dis- role of rationality as well as intuition in making moral eases. Authority/subversion intuitions might inform judgements (Saltzstein & Kasachko, 2004 ff ). This article moral judgments about and stigmatizing practices focused on exploring what resources Haidt’s approach toward people who are perceived as subverting author- oer ff s for research on infectious disease stigma, but itative rules meant to protect public health and control further research should also consider possible readjust- transmission of infectious diseases. Moreover, the con- ments of Haidt’s approach. ceptual analysis suggests that sanctity/degradation and Although our conceptual findings have to be first loyalty/betrayal intuitions can feed stigmatizing prac- empirically investigated, they suggest that stigmatizing tices toward people who are (suspected of ) carrying an practices might not be completely countered by rational infectious disease. This is partly in line with a study on persuasion. Our findings showed that the phenomenon substance use disorder. Henderson et al. (2019) showed of moral dumbfounding might explain why stigmatizing that the sanctity/degradation foundation is a predictor practices are so persistent in spite of extensive mitiga- of stigma, in which attributed stigma towards individ- tion efforts. Even when people are provided with per - uals even further increased when the purity construct suasive information that confute the underlying feeling (i.e. sanctity/degradation foundation) was triggered (i.e. transmission risks), stigmatizing beliefs and atti- within a moral multiple regression model of substance tudes that are based on that feeling remain (i.e. belief of misuse (Henderson & Dressler, 2019). In contrast with unsafety, action of not engaging in a (sexual) relation- our analysis, Henderson & Dressler also concluded that ship, both due to the ‘label’ of having HIV in this spe- the fairness/cheating foundation is such a predictor of cific example). We suggest that the sanctity/degradation stigma (Henderson & Dressler, 2019), although within intuitions have a persisting influence in this. This is one a slightly different meaning: ‘persons who expressed a more reason why we hope that the relevance of Haidt’s commitment to greater fairness were less likely to stig- work for infectious disease stigma will gain more rec- matize, while those who emphasized purity in moral ognition. Importantly, more understanding is needed judgments were more likely to stigmatize’ (Henderson about why moral dumbfounding occurs and what the 110 • Da MstÉ aND KR a MeR exact role and function of sanctity/degradation intu- should draw on empirical research regarding the intu- itions is within this phenomenon. As Haidt noted, sanc- itions that actually feed stigmatizing practices, however, tity/degradation intuitions originally evolved to protect and this study suggests that Haidt’s moral foundations oneself against pathogens and parasites (Haidt, 2012: approach oer ff s a promising new route for such research. 173). Some scholars have argued, similarly, that stig- matization has an evolutionary function as it helps to a cknowledgements prevent transmission of infectious diseases (Kurzban & Leary, 2001). However, others have argued that stigma- We would like to thank Dr F.R. Stafleu for his comments tizing practices no longer function to protect for human on an earlier draft. communities against infectious diseases or increase the ability of modern societies to survive infectious diseases, but instead only contribute to failures in protecting pub- a bout the authors lic health and the health of (stigmatized) individuals (Smith & Hughes, 2014). More research is required to Carlijn Damsté has a BSc and MSc in Biomedical better understand whether the persistence of stigma- Sciences and a MA in Applied Ethics. Dr. Koen Kramer tizing practices is indeed due to moral dumbfounding, is a postdoctoral researcher and lecturer in ethics. This what the role of sanctity/degradation intuitions is within publication is the result of the thesis that Carlijn Damsté this phenomenon, and to what extent such intuitions wrote during her MA degree, supervised by Dr. Koen are ‘hardwired’ into our brains because of the supposed Kramer. evolutionarily function of stigmatization in relation to Manuscript received: May 2022 infectious disease stigma. This study has potential for program implementers, policy makers, and researchers who aim to mitigate References stigma. It namely suggests that recognizing the existence of intuitions, next to conventional rational approaches Avert (2019). HIV Stigma and Discrimination. available (e.g. education campaigns), could contribute to more from https://www.avert.org/professionals/hiv-so- effective stigma reduction. 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Moral Intuitions About Stigmatizing Practices and Feeding Stigmatizing Practices: How Haidt’s Moral Foundations Theory Relates to Infectious Disease Stigma

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Public Health Ethics , Volume 16 (1): 10 – Mar 21, 2023
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Public HealtH etHics VOluMe 16 • issue 1 • 2023 • 102–111 102 Moral intuitions About s tigmatizing Practices and Feeding s tigmatizing Practices: How Haidt’s Moral Foundations t heory Relates to infectious Disease s tigma C. (Carlijn) Damsté Faculty of Humanities, Utrecht University, The Netherlands K. (Koen) Kramer, Faculty of Veterinary Medicine, Department of Population Health Sciences, Animals in Science and Society, Utrecht University, The Netherlands *Corresponding author: C. (Carlijn) Damsté, Utrecht University, Faculty of Humanities, The Netherlands, Email: carlijndamste@hotmail.com Despite extensive stigma mitigation efforts, infectious disease stigma remains common. So far, little attention has been paid to the moral psychology of stigmatizing practices (i.e. beliefs, attitudes, actions) rather than the experience of being stigmatized. Addressing the moral psychology behind stigmatizing practices seems nec- essary to explain the persistence of infectious disease stigma and to develop effective mitigation strategies. Our article proposes building on Jonathan Haidt’s moral foundations theory, which states that moral judge- ments follow from intuitions rather than conscious reasoning. Conceptual analysis was conducted to show how Haidt’s five moral foundations can be connected to (i) moral judgements about stigmatizing practices and (ii) stigmatizing practices themselves. We found that care/harm, fairness/cheating, loyalty/betrayal and sanctity/ degradation intuitions can inform moral judgements about stigmatizing practices. Loyalty/betrayal and sanc- tity/degradation intuitions can sometimes also feed stigmatizing practices. Authority/subversion intuitions can inform moral judgements and stigmatizing practices towards people who disrespect authoritative rules meant to protect public health. Moral dumbfounding and posthoc reasoning might explain the persistence of stigma- tizing practices. In conclusion, this study demonstrates the relevance of Haidt’s approach to infectious disease stigma research and mitigation strategies. We hope that this study motivates researchers to further test and assess this approach. e s Th tigma concept has been extensively investigated introduction by various scholars, especially within psychology and Stigma related to infectious diseases, henceforth called sociology (Goffman, 1963; Link & Phelan, 2001). Link ‘infectious disease stigma’, negatively ae ff cts many peo- and Phelan have influentially construed stigma as a phe- ple (Fischer et al., 2019). In the past, outbreaks of, for nomenon rooted in social interaction, defining it as ‘the example the plague, cholera, measles and yellow fever co-occurrence of (...) labeling, stereotyping, separation, led communities to marginalize people who were status loss, and discrimination’ and further indicating infected or thought to be infected (Kraut, 1998; Perry & that ‘for stigmatization to occur, power must be exer- Donini-Lenho, 2010 ff ). HIV-related stigma is the most cised’ (Link & Phelan, 2001: 363). Labeling relates to the well-documented infectious disease stigma in contem- social selection of a classification that is ‘affixed’ to a per - porary society (Avert, 2019), but stigmatization has also son or group, such as gender or skin color or having an occurred in relation to Covid-19 (Bhanot et al., 2020). infectious disease. These labels can be linked to a group In spite of extensive mitigation efforts, for example of undesirable characteristics leading to development through educational and awareness campaigns, infec- of stereotypes. Labeled persons can be placed in dis- tious disease stigma remains common. tinct groups, as a way to separate ‘us’ from ‘them’. When https://doi.org/10.1093/phe/phad002 Online publication date: 21 March 2023 © The Author(s) 2023. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. MORal iNtuitiONs aND stiGM atiZiNG PR actices • 103 labeling and stereotyping occur, an associated result is for policies and research targeting infectious disease general downgrading of those persons, also called status stigma. loss. Discrimination is the unfair or unjust treatment of Investigating how people respond to harmless taboo labeled persons. The role of power in stigma is some- violations (see box 1), Haidt and colleagues have con- times very clear, whereas it can also be easily overlooked cluded that moral judgments typically follow from fast ‘because in many instances power differences are so and unreflective cognitive processes, while conscious taken for granted as to seem unproblematic’ (Link & moral reasoning mainly takes place aer a m ft oral judge- Phelan, 2001: 375). ment is made, also called posthoc reasoning (Nisbett & Scholars have also come to understand stigma as a Wilson, 1977; Kunda, 1990; Kuhn, 1991; Perkins et al., category of moral interaction and experience. Yang et al. 1991; Haidt, 2001). People oen s ft truggle or fail to sup- argued that the notion of stigma is an essentially moral port their intuitive judgment regarding harmless taboo issue, as people who are stigmatized experience threats stories through conscious reasoning, but will maintain to morally relevant interests (Yang et al., 2007). They their judgment nonetheless—this is phenomenon is argued that adding moral experience to the concept of called moral dumbfounding (Björklund et al., 2000). stigma would provide new insights in understanding the Haidt and colleagues have identified five moral founda - behaviors of those involved, because this allows investi- tions or types of intuitions on which moral judgments gation of ‘what matters most’ to people who are being are based. First, care/harm intuitions ‘makes us sensi- stigmatized (Yang et al., 2007). tive to signs of suffering and need’, while ‘it makes us This article, by contrast, concerns the moral psy- eschew cruelty’ (Haidt, 2012: 178). Second, intuitions chology of stigmatizing practices rather than the of the fairness/cheating foundation make us ‘sensitive experience of being stigmatized. According to Stangl to indications that another person is likely to be a good et al., stigmatizing practices concern beliefs, attitudes (or bad) partner for collaboration and reciprocal altru- and actions, whereas stigma experiences include lived ism’ (Haidt, 2012: 178). Third, loyalty/betrayal intu- experiences (Stangl et al., 2019: 2). Practices relate to itions make us ‘sensitive to signs that another person people who stigmatize and experiences relate to peo- is (or is not) a team player’ (Haidt, 2012: 178). Fourth, ple who are being stigmatized. Addressing the moral intuitions of the authority/subversion foundation make psychology behind stigmatizing practices seems nec- us ‘sensitive to signs of rank or status, and to signs that essary to explain the persistence of infectious disease other people are (or are not) behaving properly, given stigma, and will presumably yield important lessons for their position’ (Haidt, 2012: 179). Last, the sanctity/ mitigation strategies. Our article proposes building on degradation foundation involve intuitions that are Jonathan Haidt’s work to investigate the moral psychol- evolved to protect oneself against pathogens and para- ogy of stigmatizing practices, as a promising new route sites, which ‘makes it easy for us to regard some things box 1 – Harmless taboo violations In one of his most famous investigations, Haidt asked people for responses to short stories (Haidt, 2001). These stories, which were called harmless taboo violations, describe actions that many people find oen ff sive but that do not harm anyone. An example of such a story is about Julie and Mark (see below). Aer h ft earing this story, most people immediately say that it was wrong for Julie and Mark to make love. en, Th aer ft giving their judgement, they start searching for reasons (Haidt, 2001). Haidt calls this post hoc reasoning. This happened for the story of Julie and Mark, but also for many other harmless taboo violations stories integrating with Haidt’s proposed moral foundations. From Haidt (2001), this is the story of Julie and Mark: “Julie and Mark are brother and sister. They are traveling together in France on summer vacation from college. One night they are staying alone in a cabin near the beach. They decide that it would be interesting and fun if they tried making love. At the very least it would be a new experience for each of them. Julie was already taking birth control pills, but Mark uses a condom too, just to be safe. They both enjoy making love, but they decide not to do it again. They keep that night as a special secret, which makes them feel even closer to each other. What do you think about that? Was it OK for them to make love?” (p. 814) 104 • Da MstÉ aND KR a MeR as “untouchable”, both in a bad way (because something Second, we have illustrated our analysis with exam- is so dirty or polluted we want to stay away) and in a ples from previous pilot research (Damsté & Kramer, good way (because something is so hallowed, so sacred, 2021), in which we asked seven interviewees to respond that we want to protect it from desecration)’ (Haidt, to six constructed stories that resembled Haidt’s harm- 2012: 173, 179). The sanctity/degradation foundation is less taboo violations but explicitly addressed HIV and also referred to as the ‘purity construct’ (Shweder et al., the Covid-19 stigmatization (see Supplementary mate- 1997). rial 1). The analogy between Haidt and our constructed In this article, we propose that stigmatizing prac- stories was that both concerned morally salient actions tices in relation to infectious diseases and moral judg- but excluded ex hypothesi that those actions would harm ments about such stigmatizing practices may well be anyone. This way, both types of stories help to explore influenced by the same cognitive process and moral a broader spectrum of moral intuitions than care/harm foundations that Haidt and colleagues have identified. intuitions only. The limitations of this earlier study can- As stigmatizing practices include subjective states not be overstated and we do not make any empirical related to judgements, such as beliefs and attitudes claims on how intuitions are based on the five founda- (Stangl et al., 2019), and as Haidt argues that moral tions inform stigmatizing practices. The fragments we judgements are primarily based on intuitions (Haidt, have drawn from the interviews merely serve to illustrate 2001, 2012), it makes sense to expect that both are how Haidt’s five moral foundations can sometimes be related. We show how Haidt’s five moral foundations recognized in peoples’ conversations regarding stigma can be conceptually connected to moral judgements and infectious diseases. We hope that this will motivate about stigmatizing practices regarding infectious dis- adequately resourced researchers to build on Haidt’s eases and to such stigmatizing practices themselves. work to study infectious disease stigma empirically. We enrich this conceptual analysis with examples For our earlier study, a posthoc ethical approval was from our previous work (Damsté & Kramer, 2021), in given by the Faculty Ethics assessment Committee of the which we asked seven people to respond to our con- Faculty of Humanities (reference number: 22-161-01). structed stories that resembled Haidt’s harmless taboo e s Th tudy did not pose any credible physical, psycho- violations but explicitly addressed infectious diseases logical, social or economic risks to our interviewees and and stigmatization. We thus argue that moral intu- data management and informed consent procedures itions can be expected to inform moral judgements met generally accepted standards. about stigmatizing practices, and sometimes even to feed those practices themselves, and illustrate how concepts from Haidt’s moral foundations theory may Findings: how Haidt’s moral apply in particular cases. foundations can be conceptually linked to moral judgements Methods about stigmatizing practices and stigmatizing practices themselves As a first step, we have mapped conceptual connections between infectious disease stigmatization on the one In this section, we demonstrate how Haidt’s moral foun- hand and Haidt’s five moral foundation on the other. dations can be conceptually linked to moral judgements This explorative desk research considered how the con- and stigmatizing practices in the context of infectious cepts defining each moral foundation (care/harm, fair - diseases. We elaborate on each foundation and close ness/cheating, loyalty/betrayal, authority/subversion, with the phenomenon of moral dumbfounding. Table sanctity/degradation) relate to concepts associated with 1 presents an overview of how the foundations can be infectious diseases and stigmatization. Our analysis conceptually linked to judging about stigmatizing prac- shows how the five foundations are a priori likely to (i) tices and stigmatizing practices themselves. inform moral judgements about stigmatizing practices To enrich this conceptual analysis and to illustrate related to infectious diseases, and to (ii) feed infectious the conceptual connection between Haidt’s foundations disease stigma. This helps to construct stories that can and stigmatizing practices, we show how different intu- be used (similarly to Haidt’s harmless taboo stories) to itions can be recognized in sample fragments from pilot trigger peoples’ moral intuitions with respect to this interviews. These fragments sometimes feature stigma- topic. tizing components, including labeling, stereotyping, MORal iNtuitiONs aND stiGM atiZiNG PR actices • 105 t able 1. Conceptual examples of intuitions that inform moral judgements about stigmatizing practices (i.e. beliefs, attitudes, actions) and intuitions that feed stigmatizing practices per moral foundation Moral foundation Examples that intuitions inform moral judgements Examples that intuitions feed stigmatiz- about stigmatizing practices ing practices Care/harm Not providing someone in need care, because she - has an infectious disease, is wrong Fairness/cheating Not hiring someone because of her infectious - disease, when she would pose no significant trans- mission risk to her colleagues, clients, or others, is unfair Loyalty/betrayal Not caring for people in your ingroup because they Members from one’s ingroup should have an infectious disease is disloyal; be protected from people that could Banishing an ingroup members that have an infec- transmit infectious diseases to them, by tious disease is wrongful shutting such people out of the ingroup Authority/subver- Not following up rules that authorities have estab- Someone who does not adhere to rules sion lished to protect public health, such as to repress an meant to protect public health and con- infectious disease pandemic, is wrong trol transmission of infectious diseases is labeled and discriminated for this Sanctity/degrada- Sticking of the label ‘dangerous because of potential Someone with an infectious disease is tion transmission’, in case when there is no transmission labeled as polluted, impure; risk, is unfair Not engaging in a (sexual) relationship because of the infectious disease, even if it cannot be transmitted anymore, just to be on the safe side Within this foundation, the trigger for (moral judgements about) stigmatizing practices is different compared with the other foundations: it is about non-adherence to authoritative rules related to infec- tious diseases, rather than to the infectious disease itself. separation, status loss and/or discrimination (Link & give help [bring food] if you can. Yes. If you know about that.” Phelan, 2001). An infectious disease is contagious and transmittable in nature, although under certain circumstances it can The Care/Harm Foundation also be untransmittable. If there is a transmission risk, e c Th are/harm foundation makes us sensitive to signs care/harm intuitions might weigh more heavily in moral of suffering and need, and the concepts of suffering judgements, as there is a potential harm to prevent to and need connect to infectious diseases in clear ways. others. But if there is no transmission risk, there is no Care/harm intuitions will presumably trigger feelings potential harm (i.e. transmitting or contracting the of care for someone who is (seriously) ill because of an infectious disease) to prevent, and one would expect infectious disease, or is perceived to suffer from some to see this reflected in intuitions and judgements about other type of harm due to the infection, including men- how to treat people carrying infections. (As explained tal stress due to stigmatization. It makes us share in the below, however, this expectation may well be frustrated pain of others and to wish to avoid harm for them. These by the persistence of sanctity/degradation intuitions.) intuitions can thus give rise to moral judgements that When there is a transmission risk, this foundation you should care for someone in need. ‘Need’ is a broad could well give rise to an urge to prevent further trans- concept and can vary from the need for care to the need mission of infectious diseases, given the potential harm for food, which the fragment below refers to: of transmission involved (of note: this can also be related to the loyalty/betrayal foundation, which is further dis- “If she is housebound at some point, due to the cussed below). If someone poses a transmission risk to [Covid-19] quarantine, then I think you should 106 • Da MstÉ aND KR a MeR another, this might evoke moral judgements about risky ‘bad collaborators’. It suppresses free riding (i.e. receiv- behavior and that this person does not care for others ing the benefits of cooperation without carrying the (i.e. does not prevent transmission) which is a wrong- costs). Someone who has an infectious disease but acts ful act. As care/harm intuitions are focused to care for carelessly (i.e. posing transmission risks), whereas oth- the other, rather than oneself, this foundation would not ers do act in a careful way toward this person, might be provoke judgements about an urge to protect oneself (of judged as a bad partner for collaboration. note: the urge to prevent transmission to oneself does “If he highly appreciated that his friend cancelled come back with sanctity/degradation intuitions, as dis- the appointment the previous time [due to hav- cussed below). ing Covid-19-related symptoms], then it seems to me that you should do the same. (…) If you did “I think that Tom just shouldn’t take that risk appreciate that your friend does so [cancelling [of visiting the birthday of his grandparents the appointment], but you yourself prefer your with Covid-19-related complaints], because own advantage and want to have fun, well, I don’t they just really… If he transmits something, think that’s a good thing.” then he will have to carry that burden for the rest of his life. I: in what way? R: well, I think Moreover, the fairness/cheating foundation might trig- that, if you, if you do something like that and it ger intuitions and moral judgements about unequal goes wrong, then it’s something which poses a rights, for example in case of not hiring someone on the heavy burden on you because you proved that, basis of an HIV-positive status, which seems unfair if you did harm to your grandparents, and per- hiring the applicant would not pose a significant health haps even caused their deaths. So that seems to me, seems clear to me that you just shouldn’t risk to her prospective colleagues, customers, etc. e Th take that risk.” example below shows that fairness/cheating intuitions inform moral judgements and create certain awareness However, in cases where there is no transmission risk, that stigma is involved (i.e. saying that it is discrimina- one would expect care/harm intuitions to be more tion to not hire someone with the label ‘having HIV’). focused on the already existing harm of having an This shows that fairness/cheating intuitions can inform infectious disease for others, and the associated feel- judgements about stigmatizing practices, even though ings of caring for or compassion for someone’s situa- these intuitions do not necessarily lead to those prac- tion. Someone who refrains from offering someone tices themselves. care because that person has an infectious disease may well be judged as acting wrongly on these grounds “My first feeling is that it [not hiring due to HIV] is simply not allowed at all, that it’s discrimina- (especially if providing care would not expose the tion. I: and what makes it discrimination? R: well, caregiver to significant (transmission) risks). Not it’s just like you won’t hire a women because of offering care can in such a case be considered a form her wish to have a child.” of discrimination, prompted by the person’s ‘label’ as someone having an infectious disease, and thus as a Another perspective is that fairness/cheating intuitions stigmatizing practice. This suggests that care/harm might contribute to being aware of structural forms of intuitions can inform moral judgements about stig- stigma. A similar case as argued by Henderson et al. on matizing practices, although they do not necessarily substance misuse could be made here (Henderson & feed stigmatizing practices themselves. Dressler, 2019): strong disapproval of inequality might result in recognition of structural processes that lead “If you can’t communicate at distance, it [caring to contracting infectious diseases (such as increased for someone with Covid-19] is more difficult I HIV risk among trafficked women (Yu et al., 2021) have to say, because then you would have to ring the bell, to really converse with each other, and I or increased Covid-19 risk among economically dis- don’t know if I would feel completely comfortable advantaged groups (Patel et al., 2020)), which could with that.” be associated with thinking that having an infectious disease is not fully a personal choice. In other words, not everyone has equal chances of contracting a certain The Fairness/Cheating Foundation infectious disease. These intuitions might thus make e fa Th irness/cheating foundation pertains to reciprocal people sensitive for signs of inequality in contracting altruism. It makes us want to punish cheaters, who do infectious diseases, which relates to being aware of not stand for mutual collaboration and who are thus structural stigma. MORal iNtuitiONs aND stiGM atiZiNG PR actices • 107 adhere to the Covid-19 rules and thereby show a lack of The Loyalty/Betrayal Foundation respect for authority. Stigmatization does not occur here Loyalty/betrayal intuitions can be expected to arise because the person stigmatized is (suspected of ) having when the infectious disease influences relationships. an infectious disease, but due to their (perceived) non- Next to the care/harm intuitions as discussed above, adherence to rules meant to protect public health and the urge to prevent further transmission of infectious to contain the transmission of infectious diseases. Such diseases might also be fed by loyalty/betrayal intu- behavior might trigger the authority/subversion founda- itions. As preventing transmission is a form of caring tion and can hence lead to dismissive moral intuitions. for another, one might say that preventing trans- es Th e intuitions might in turn motivate stigmatizing mission towards others of your ingroup (e.g. family, practices, for example labeling and stereotyping the friends) is part of loyalty within your relationships. person as a ‘wappie’ (a Dutch neologism from Covid-19 This suggests that loyalty/betrayal intuitions can be a times that roughly means ‘a weirdo who is out of touch motivation for stigmatizing practices toward people with reality’), which implies a loss of status and invites outside of one’s ingroup: the urge to loyally protect separation and discrimination. Although the trigger for friends and family can easily lead to separation from stigmatizing practices is different on this moral founda- people labeled as risky for one’s ingroup. In the early tion compared with the other foundations (namely, the Covid-19-pandemic times, for example households perception that someone subverts authoritative rules or small groups of friends agreed to only see each related to infectious disease control and public health other, to limit cross transmission and extra contacts protection rather than (the suspicion) that someone from outside, in order to create a ‘safe bubble’ with carriers an infectious disease), it can motivate stigmati- each other. Sometimes, this occurrence went so far zation in relation to infectious diseases. that people were labeled as ‘safe’ (e.g. the ones who strictly adhere to the Covid-19 rules) or ‘unsafe’ (e.g. The Sanctity/Degradation Foundation the ones who did see others and were loose with the Covid-19 rules)—and that preference was given to At last, the sanctity/degradation foundation can be only let in the ‘safe’ people within ones bubble. expected to trigger intuitions about infectious diseases Second, when you refrain from providing close rela- or people with an infectious disease, simply because of tives due care, this might be considered as an act of dis- the infectious nature or related characteristics of, e.g. loyalty. An extreme example of separation is banishment how such an infection is (assumed to be) contracted. of ingroup members such as friends or family, due to Having an infectious disease may be labeled as being a person’s infectious disease. Loyalty/betrayal intuitions ‘impure’ as it is something from outside interrupting the can help someone to recognize that such practices are sanctity of the body. When this foundation is triggered, stigmatizing and morally problematic. this is likely to result in negative judgements (Haidt, 2012). For example, if the infectious disease is obtained “You can’t blame her for what happened to her, through unsafe sex or unsafe needle use, this could trig- can you? I mean, if your child contracted a dis- ger judgements that these acts have desecrated the body. ease which, well… Then it’s simply just bad for On the other hand, if the infectious disease is obtained her. Then you should even love her more, so to speak, be extra concerned, especially in such through bad luck, this might not trigger this foundation. times close her in your arms, and not sending In addition, sanctity/degradation intuitions may away. Those are things I just cannot imagine.” make people want to stay away from people who are potential sources of infection, even when there is no In sum, loyalty/betrayal intuitions can inform moral actual transmission risk, just to be on the safe side. For judgements about stigmatizing practices toward people example, sanctity/degradation intuitions could explain in one’s ingroup. On the other hand, loyalty/betrayal why people might still feel unsure about entering into intuitions can probably lead to stigmatizing people who a sexual relationship with someone who has a positive are labeled as a risk to one’s ingroup. HIV-status but cannot transmit the virus because effec- tive treatment (Eisinger et al., 2019): The Authority/Subversion Foundation “I would not engage so quickly in a sexual contact e a Th uthority/subversion foundation concerns respect with a person who has HIV. But suppose it hap- for authority and status and will presumably trig- pens, sexual contact, I would just use condoms ger moral judgements about, e.g. people who do not then, even if there is perhaps no risk anymore, 108 • Da MstÉ aND KR a MeR but just to be sure. I: and why? Because you say, I might get sick. That I can get it [HIV]. Even would use it, even when the risk is not there any- though it is treatable and it is said that it cannot more, but to be sure. How does that work in your be transmitted anymore, but well you don’t know mind? R7: yes stupid, yes it’s a bit crazy actually. that. I: what don’t you know? R: that it is not (…) On the one hand I would say, do what makes transmittable. I: but that’s what I just said. R4: yes you feel good, and use condoms or don’t use it, [elongated yes], that’s what you say. [laughs] I: but whatever you feel comfortable with. On the other what is it then, why do you think this? R: well, I hand, I keep having a bit of a dirty feeling in my don’t know. It’s something of uncharted territory. mind then, that it might be transmitted one day. I: and what if that whole territory is known? R: Yes, it’s a bit of a crazy feeling what is in my mind yes, there is always a risk, everywhere is a risk. or something, can’t really explain it either.” See, when I get a little shot soon [Covid-19 vac- cine], then I can still get it, it isn’t 100% sure that Avoidance due to perceived transmission risks, while I can’t get it. Nothing can be ever ruled out with there are no such risks, might be judged as avoidance 100% certainty. So even if it is well treatable, then on wrong grounds. Examples might be not engaging in there is always a risk, always a chance, that you still can get it. I: and suppose, very hypothetically, a sexual relationship with someone with HIV but who it is not, there is no risk, there is no chance. R: is under effective treatment or keeping additional dis- well look, it never just goes wrong because of the tance while someone is already recovered from Covid- disease of course, but. I: what do you mean? R: 19 and cannot transmit anymore. e Th act in itself can be well, see, a relationship with someone is not only considered as a stigmatizing practice—the label of ‘dan- about a disease, it’s also about how the person is, if gerous because of potential transmission’ sticks unjusti- you can get along together, there are many things. fiably and leads to separation. This shows that sanctity/ I: and if that’s also all okay? R: yes why not? Yes. degradation intuitions can inform moral judgements But yes, that is, but yes. Well, in principle, then it about stigmatizing practices as well as underlie stigma- is, then it could be. I: and would you feel comfort- tizing practices. able with it, with such a relationship? R: [silence] I think so yes. Hypothetically speaking. [laughs] I: yes? R: well, you just say, if everything, if you Moral Dumbfounding and Post- can’t get it. Then nothing is wrong, right. I: okay, and you have to laugh now, does it really feel so? hoc Reasoning: When intuitive R: well, that’s so, if it really isn’t... But in my opin- Judgements and c onscious ion, there is always a bit of ambiguity, and I think that would always gnaw a bit.” Reasoning do not a gree and How t his Might Maintain s tigmatizing In this fragment, the respondent expresses doubts about engaging in a (sexual) relationship due to the risks Practices of transmission, and for the most part judges that it Moral dumbfounding occurs when people struggle or would be better not to have such a relationship. When fail to support their intuitive judgement but will main- the person gets access to rational arguments that HIV tain their judgement nonetheless (Björklund et al., 2000). is untransmittable due to effective treatment, extensive This might explain why people maintain to stigmatizing posthoc reasoning occurs, in which the respondent practices (i.e. beliefs, attitudes, actions), even when they seeks to support his judgment by oer ff ing reasons to have access to persuasive arguments that disprove their doubt the effectiveness of the antiviral treatment. This intuitive judgements leading to stigmatizing practices. suggests that the respondent’s judgment is based on e f Th ragment below exemplifies how dumbfounding sanctity/degradation intuitions rather than (only) care/ can occur within the context of infectious diseases and harm intuitions, but is rationalized in terms of harm. how it can feed stigmatizing practices. Although more Even when the respondent accepts (at least for the sake research is required and we do not intend to make any of argument) that there is no risk of transmission, the substantive claims here, we hope that other researchers judgment that it would be better to avoid having this will be motivated to explore this further. type of relationship does not fully disappear. This is arguably an example of moral dumbfounding, where “Yes that person then indicates that he has it an intuitive moral judgment is maintained (by persist- [HIV], yes God, what kind of risks does that ing sanctity/degradation intuitions) even though argu- entail, does it have impact on the health of for example me, or well, what is the risk that I ments for that judgment fail. The fragment provided in MORal iNtuitiONs aND stiGM atiZiNG PR actices • 109 the previous subsection (see page 13) provides another & Dressler, 2019: 16). This does not contradict our find- example of someone struggling to rationalize their intui- ing that fairness/cheating intuitions can inform moral tive judgement, and even self-consciously admitting that judgements about stigmatizing practices rather than they lack a ‘real’ explanation, without relinquishing that feed stigmatizing practices. judgment. Nevertheless, empirical investigation is needed first to assess our conceptual analysis and to further test the potential of our approach. It is necessary to draw firmer conclusions concerning the influence of moral intuitions Discussion on moral judgements and stigmatizing practices within To the best of our knowledge, this is the first study that the context of infectious diseases in order to make sub- examines whether and how Haidt’s theory on moral stantive claims about the full ability of this approach. intuitions can be conceptually linked to stigmatizing We hope that our conceptual analysis motivates ade- practices related to infectious diseases. We conducted quately resourced researchers to build on Haidt’s work desk research including a conceptual analysis. Our to empirically examine stigmatizing practices related findings showed that Haidt’s moral foundations, in the to infectious diseases. Such research can draw on our context of infectious diseases, can be conceptually con- conceptual analysis to construct additional stories nected to moral judgements about stigmatizing practices related to infectious disease stigma, which would give and sometimes to stigmatizing practices themselves. We more insight into the role of moral intuitions in stigma- enriched this conceptual analysis with examples from tizing practices in a wealth of situations. Within these previous work. It demonstrated the potential of applying further investigations, possible limitations of the moral Haidt’s moral foundations theory to infectious disease foundations theory should also be considered. One cri- stigma, and thereby oer ff s an innovative perspective tique is that the sanctity/degradation foundation is het- to respond to stigmatizing practices around infectious erogenous: it has been argued that the construct lacks diseases. a coherent understanding (Gray et al., 2022). Others Our analysis suggest that care/harm, fairness/cheat- have questioned Haidt’s theory for (more or less com- ing, loyalty/betrayal, and sanctity/degradation intuitions pletely) rejecting the role of rational reasoning in moral indeed have the potential to inform moral judgements judgement formation, rather than acknowledging the about stigmatizing practices regarding infectious dis- role of rationality as well as intuition in making moral eases. Authority/subversion intuitions might inform judgements (Saltzstein & Kasachko, 2004 ff ). This article moral judgments about and stigmatizing practices focused on exploring what resources Haidt’s approach toward people who are perceived as subverting author- oer ff s for research on infectious disease stigma, but itative rules meant to protect public health and control further research should also consider possible readjust- transmission of infectious diseases. Moreover, the con- ments of Haidt’s approach. ceptual analysis suggests that sanctity/degradation and Although our conceptual findings have to be first loyalty/betrayal intuitions can feed stigmatizing prac- empirically investigated, they suggest that stigmatizing tices toward people who are (suspected of ) carrying an practices might not be completely countered by rational infectious disease. This is partly in line with a study on persuasion. Our findings showed that the phenomenon substance use disorder. Henderson et al. (2019) showed of moral dumbfounding might explain why stigmatizing that the sanctity/degradation foundation is a predictor practices are so persistent in spite of extensive mitiga- of stigma, in which attributed stigma towards individ- tion efforts. Even when people are provided with per - uals even further increased when the purity construct suasive information that confute the underlying feeling (i.e. sanctity/degradation foundation) was triggered (i.e. transmission risks), stigmatizing beliefs and atti- within a moral multiple regression model of substance tudes that are based on that feeling remain (i.e. belief of misuse (Henderson & Dressler, 2019). In contrast with unsafety, action of not engaging in a (sexual) relation- our analysis, Henderson & Dressler also concluded that ship, both due to the ‘label’ of having HIV in this spe- the fairness/cheating foundation is such a predictor of cific example). We suggest that the sanctity/degradation stigma (Henderson & Dressler, 2019), although within intuitions have a persisting influence in this. This is one a slightly different meaning: ‘persons who expressed a more reason why we hope that the relevance of Haidt’s commitment to greater fairness were less likely to stig- work for infectious disease stigma will gain more rec- matize, while those who emphasized purity in moral ognition. Importantly, more understanding is needed judgments were more likely to stigmatize’ (Henderson about why moral dumbfounding occurs and what the 110 • Da MstÉ aND KR a MeR exact role and function of sanctity/degradation intu- should draw on empirical research regarding the intu- itions is within this phenomenon. As Haidt noted, sanc- itions that actually feed stigmatizing practices, however, tity/degradation intuitions originally evolved to protect and this study suggests that Haidt’s moral foundations oneself against pathogens and parasites (Haidt, 2012: approach oer ff s a promising new route for such research. 173). Some scholars have argued, similarly, that stig- matization has an evolutionary function as it helps to a cknowledgements prevent transmission of infectious diseases (Kurzban & Leary, 2001). However, others have argued that stigma- We would like to thank Dr F.R. Stafleu for his comments tizing practices no longer function to protect for human on an earlier draft. communities against infectious diseases or increase the ability of modern societies to survive infectious diseases, but instead only contribute to failures in protecting pub- a bout the authors lic health and the health of (stigmatized) individuals (Smith & Hughes, 2014). More research is required to Carlijn Damsté has a BSc and MSc in Biomedical better understand whether the persistence of stigma- Sciences and a MA in Applied Ethics. Dr. Koen Kramer tizing practices is indeed due to moral dumbfounding, is a postdoctoral researcher and lecturer in ethics. This what the role of sanctity/degradation intuitions is within publication is the result of the thesis that Carlijn Damsté this phenomenon, and to what extent such intuitions wrote during her MA degree, supervised by Dr. Koen are ‘hardwired’ into our brains because of the supposed Kramer. evolutionarily function of stigmatization in relation to Manuscript received: May 2022 infectious disease stigma. This study has potential for program implementers, policy makers, and researchers who aim to mitigate References stigma. It namely suggests that recognizing the existence of intuitions, next to conventional rational approaches Avert (2019). HIV Stigma and Discrimination. available (e.g. education campaigns), could contribute to more from https://www.avert.org/professionals/hiv-so- effective stigma reduction. 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Public Health Ethics – Oxford University Press

Published: Mar 21, 2023

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