Utilitarian psychology and influenza vaccine acceptance in the United Arab Emirates: implications for moral education and public policy

Abstract

Seasonal influenza is still a challenge in the United Arab Emirates (UAE). There is consensus that the most effective way to address this problem is through yearly vaccination campaigns. Despite governmental efforts to make the influenza vaccine available, there remains some hesitancy among the population. Previous research has focused on the conspiratorial and disinformation aspects of vaccine hesitancy. In this article, we posit that, apart from those factors, moral psychology considerations also play a role in determining whether people accept the influenza vaccine. University students in the UAE were assessed in their knowledge of how vaccines work. They were also assessed in their level of adherence to utilitarian moral psychology. Results came out showing that while vaccine knowledge plays a role in the decision to receive the seasonal influenza shot, impartial beneficence (as a dimension of utilitarian psychology) plays a greater role. This has implications for moral education, communication and public policy in the UAE, as an introduction to utilitarian principles may serve the purpose of curbing vaccine hesitancy in the nation.

Introduction

Seasonal influenza remains a problem worldwide. It is estimated that each year 3–5 million people suffer a severe form of the disease [1]. Although not particularly alarming, the United Arab Emirates (UAE) faces some difficulties on this issue, as flu outbreaks have been reported each year towards the end of summer [2]. There is consensus that the best approach to the persistent problem of seasonal influenza is effective vaccination [3]. This should be administered on a yearly basis, as the immune system needs a constant boost, in anticipation of the risks brought forth by the seasonal changes [4].

Prior research has established that attitudes towards vaccination are influenced by a complex interplay of cognitive, cultural, and psychological factors. One of the primary factors is trust in public health institutions and science. Individuals with higher levels of trust in these institutions and a positive attitude towards science are more likely to accept vaccines [5, 6]. Conversely, those with lower trust levels may be more hesitant or resistant to vaccination.

Information and science literacy also play crucial roles in shaping vaccination attitudes. People with higher levels of information and science literacy tend to have more positive attitudes towards vaccines [7]. This is likely because they are better equipped to understand and evaluate scientific information about vaccine safety and efficacy. Additionally, access to accurate information and the ability to critically assess it can help counter misinformation and conspiracy theories that often fuel vaccine hesitancy [8].

Social and cultural factors significantly influence vaccination attitudes. Social norms, peer influence, and family attitudes can shape an individual’s perception of vaccines [9]. For instance, if vaccination is widely accepted and encouraged within a person’s social circle, they are more likely to view it positively. Cultural factors, including religious beliefs and political ideology, can also impact vaccine acceptance [10].

Psychological characteristics and personality traits are associated with vaccination attitudes. Studies have found that individuals with higher levels of gratitude, extraversion, agreeableness, and conscientiousness tend to be more accepting of vaccines [11]. Conversely, those with higher levels of neuroticism or experiencing depression and anxiety may be more hesitant. Additionally, mental flexibility has been linked to vaccination attitudes, with more cognitively flexible individuals potentially being more open to new information about vaccines [12].

Perceptions of risk and benefit play a crucial role in shaping vaccination attitudes. People who perceive a higher risk from the disease and lower risk from the vaccine are more likely to accept vaccination [13]. Concerns about vaccine safety, particularly potential short-term and long-term side effects, are common reasons for vaccine hesitancy. The perceived effectiveness of vaccines in preventing disease also influences attitudes, with higher perceived effectiveness associated with greater acceptance.

In the specific case of flu vaccination, research suggests that attitudes are influenced by perception of influenza severity. Many individuals underestimate the potential seriousness of seasonal flu, with 15.9% of participants in one study not considering influenza as a threat [14].

Practical barriers also play a role in influenza vaccination attitudes. Lack of awareness about vaccine availability was cited by 50.1% of unvaccinated participants as the most common reason for not getting vaccinated [14]. Additionally, convenience factors such as the frequency of health check-ups and knowledge about free vaccine availability have been associated with higher vaccination rates [15]. These findings suggest that improving access to information about seasonal flu vaccines and making vaccination more convenient could positively influence attitudes and uptake rates.

As with many other vaccines, the problem of hesitancy persists. Much research has been previously done on the main factors that lie behind vaccine hesitancy. Conspiracy mongering is one such factor extensively documented. Pertwee et al. [16] explain that major factors, “such as anxieties around the pace of technological change or feelings of political disempowerment, are not within the control of the medical community.” This implies that despite the major breakthroughs in protection against viral infections, a wider psychosocial aspect remains an obstacle to the effective management of viral epidemics. Possibly due to political transformations and the global shift towards populist political styles [17], conspiracy theories are on the rise worldwide [18], and many of these theories target medical aspects. In the UAE, vaccine hesitancy is still a problem [19], although there is currently very little research on the role that conspiratorial thinking may play in this regard.

Medical conspiracy theories ultimately lead to disinformation [20], and consequently, knowledge about vaccines has also been extensively documented as a predictor of people’s willingness to receive the vaccine. Previous studies report that higher educational levels predict greater acceptance of vaccine jabs [21]. But this also pertains to specific knowledge about vaccines [22], and on that basis, governments have realized that the best approach to curb vaccine hesitancy is through educational efforts [23,24,25]. In the UAE, this educational approach has been embraced extensively [26,27,28].

Most of these educational approaches focus on facts and scientific information. But very little attention has been given to the moral aspect of educational efforts to curb vaccine hesitancy. Particular modes of moral reasoning may be significantly effective in motivating people to receive vaccine jabs. Utilitarianism is a good candidate in this regard. Traditionally, utilitarianism in moral psychology has been viewed with some suspicion, due to its documented associations with psychopathy [29,30,31,32]. In trolley dilemmas, the utilitarian option (especially in the footbridge scenario) has been associated with alcohol intoxication [33] and Machiavellianism as personality traits [34, 35].

Yet, moral decisions to release vaccines despite their known risks are usually made on the basis of utilitarian calculations [36,37,38,39]. Given that vaccinations seek to maximize protection but may occasionally incur in side effects, utilitarian considerations strongly support vaccination programs. As Cornelius [36] explains, “utility is measured by results. This simplifies the mathematics of utility because it is much easier to quantify end results of actions than be concerned with intentions or the substance of the actions themselves… Vaccinations are examples of utilitarianism being put to practice… Each member of society individually takes a small risk of the side effects of the vaccination to insure that the society as a whole is significantly more healthy.”

There is a common misconception that utilitarianism is equivalent to ethical egoism, but this is far from the truth. Utilitarianism, as developed by philosophers like Jeremy Bentham and John Stuart Mill, aims to maximize overall well-being or happiness for the greatest number of people, not just for the individual [40]. As Slote [41] explains, “if something is permissibly done or obligatory to do with respect to one individual, it is permissible or obligatory in regard to any other individual, as long as the pleasure related causal facts behind such moral judgements remain otherwise the same.”

In contrast, ethical egoism posits that moral agents should act solely in their own self-interest [42].The key distinction lies in the scope of consideration. Utilitarianism requires individuals to consider the consequences of their actions on all affected parties, not just themselves. It operates on the principle of neutrality, treating everyone’s pleasure and pain as equally valuable, regardless of who experiences it. This egalitarian foundation is fundamentally at odds with the self-centered approach of ethical egoism.

Utilitarianism is closely related to altruism, as both ethical frameworks prioritize the well-being of others. While utilitarianism aims to maximize overall happiness for the greatest number of people, altruism focuses on selfless concern for others’ welfare [43]. Effective Altruism, a modern movement inspired by utilitarian thinking, exemplifies this relationship by encouraging individuals to use evidence and reason to determine how they can do the most good for others, often through charitable giving or career choices that maximize positive impact [44]. However, it is important to note that while utilitarianism and altruism share common ground, they are not identical; utilitarianism provides a specific framework for decision-making based on consequences, while altruism is a broader concept of selfless concern for others that can be incorporated into various ethical systems.

Research question and hypothesis

On the basis of these considerations, the main research question is as follows: 1) can adherence to utilitarianism be used as a predictor of vaccine acceptance in the population at large? If so, is adherence to utilitarianism (in either of its dimensions) a stronger predictor of influenza vaccine intake, than other factors traditionally assumed to be relevant, such vaccine knowledge?

Our working hypothesis is that adherence to utilitarianism is indeed associated with influenza vaccine intake, and that this predictor is stronger than vaccine knowledge.

Additionally, we seek to answer the following research question: 2) is there an association between the two dimensions of utilitarianism, and in turn, do those dimensions have an association with vaccine knowledge?

On the basis of the research question and hypothesis presented above, a more general and philosophical question is now presented: should public health policies dedicate efforts to utilitarian aspects of moral education, as an indirect effort to curb vaccine hesitancy? Since this is a normative question, it cannot be answered exclusively on the basis of empirical data, but rather, on the basis of some philosophical reflection Nevertheless, the results obtained from the preceding questions can shed light on this particular issue.

Methods

Research protocols were approved by Ajman’s University Research Ethics Committee, # M-H-F-17-Nov, and protocols were in accordance with the Helsinki Declaration. Sample size was calculated on the basis of Slovin’s formula, with a 95% confidence level, 5% margin of error. The recommended sample size was 385. On the basis of convenient sampling (based on availability and willingness to answer a survey), 333 participants were recruited (response rate was therefore 86%). Inclusion criteria was being an adult, being fluent in English, and being a university student in the United Arab Emirates.

Responses collected through a direct and secure method to ensure the integrity of the data. Each participant was approached face-to-face and invited to participate in the study. Upon agreeing to participate, they scanned a QR code using their mobile phone, which directed them to the survey. Participants then completed the survey independently and submitted their responses without any assistance. A small number of participants received the QR code via email; however, they also completed the survey in private, ensuring that their answers remained confidential and free from external influence. This approach minimized bias and allowed for more accurate data gathering.

The survey had 4 sections. First, demographic information was collected (age, gender).

Second, the Oxford Utilitarianism Scale (OUS) was included. This is a 9-item survey that assesses the level to which participants endorse utilitarian positions in their ethical decisions [45]. The OUS has two dimensions: impartial beneficence and instrumental harm. “Impartial beneficence” has 5 items (e.g., “It is just as wrong to fail to help someone as it is to actively harm them yourself”) that measure the extent to which subjects are willing to help others from a completely impartial perspective, regardless of whether they are relatives or friends. “Instrumental harm” has 4 items (e.g., “Sometimes it is morally necessary for innocent people to die as collateral damage—if more people are saved overall”) that measure the extent to which subjects are willing to sacrifice others, so as to save a greater number of people, thus maximizing utility. Items are rated on a Likert scale from 1 to 5, with participants expressing their level of agreement with the item (1 = Strongly disagree; 5 = strongly agree). Higher scores therefore indicate greater adherence to utilitarian thinking. The OUS has been properly validated [46], and it is considered to have adequate reliability [47]. In the present study, Cronbach’s alpha for the OUS is 0.77, indicating good reliability of the instrument.

This particular scale was chosen due to its validated and reliable measure of utilitarian thinking. The OUS captures two key dimensions of utilitarianism: impartial beneficence and instrumental harm. Impartial beneficence refers to the willingness to help others from a completely impartial perspective, regardless of personal relationships or proximity. This dimension reflects the utilitarian ideal of maximizing overall well-being for all individuals equally. Instrumental harm, on the other hand, measures the willingness to sacrifice individuals for the greater good, even if it means causing harm to innocent people. This aspect aligns with the utilitarian principle of maximizing utility, even when it requires difficult moral trade-offs.

These two subconstructs, while distinct, interact under the broader framework of utilitarianism. Impartial beneficence represents the more widely accepted dimension of utilitarianism, focusing on promoting the well-being of all sentient beings impartially. Instrumental harm, in contrast, represents the aspect of utilitarianism most people struggle with, which allows for morally controversial actions if they result in greater overall benefits. Together, these dimensions capture the essence of utilitarian thinking: the impartial maximization of welfare, even if it requires sacrificing some for the benefit of many. This comprehensive approach allows the study to explore how different aspects of utilitarian thinking may predict adherence to seasonal influenza vaccination, providing a nuanced understanding of the relationship between moral beliefs and health decisions.

Third, a vaccine knowledge scale devised by Zingg and Siegrist [48] was included. This is an instrument composed of 9 items, which assess subjects’ knowledge about how vaccines work. Items are arranged on a Likert Scale from 1 (strongly disagree) to 5 (strongly agree), presenting true statements (e.g., “The immune system of children is not overloaded through many vaccinations”) and false statements (e.g., “Many vaccinations are administered too early, so that the body’s own immune system has no possibility to develop”); false statements were scored reversely. The score of each item was then coded; responses with scores from 1 to 3 were categorized as “miss”, responses with scores from 4 to 5 were categorized as “hits.” “Miss” was then given a value of 0, “hit” was given a value of 1. The coded scores of each item were then added, and that returned the grand score for the vaccine knowledge scale. Higher scores indicate a higher level of knowledge of how vaccines work.

Fourth, the following question was asked: “Have you received the seasonal influenza vaccine in the last 6 months, or do you intend to do so in the coming 6 months?”, with Yes/No as options.

In order to answer the first research question (can adherence to utilitarianism be used as a predictor of vaccine acceptance in the population at large? If so, is adherence to utilitarianism (in either of its dimensions) a stronger predictor of influenza vaccine intake, than other factors traditionally assumed to be relevant, such vaccine knowledge?), a logistic regression model was built. Influenza vaccine acceptance was the outcome variable; instrumental harm, impartial beneficence and vaccine knowledge were the predictors. Scores were standardized so as to make uniform comparisons across variables. Assumptions for collinearity were met (highest VIF was 1.26). Statistical significance was placed at p ≤ 0.05.

In order to answer the second research question (“is there an association between the two dimensions of utilitarianism, and in turn, do those dimensions have an association with vaccine knowledge?”), Spearman’s coefficients were calculated for correlations across instrumental harm, impartial beneficence and vaccine knowledge. Statistical significance was placed at p ≤ 0.05.

Statistical analyses were done using Jamovi software.

Results

Descriptive

We collected a total of 333 responses. The participants had a mean age of 21 years, with ages ranging from a minimum of 18 to a maximum of 26 years, and a standard deviation of 1.87 years, indicating relatively low variability in age distribution. The sample comprised 42.6% men (142 participants) and 57.4% women (191 participants), providing a balanced perspective across genders for the analysis.

Descriptive statistics are presented in Table 1.

Table 1 Descriptive statistics for the variables of the study

Results for research question 1

The results of the logistic regression model is presented in Table 1.

The model demonstrated a significant overall fit, as indicated by a chi-square statistic of X²(3) = 209, p < 0.001. This suggests that the model successfully captures the variability in vaccine intake based on the included predictors. All three predictors—Instrumental Harm, Impartial Beneficence, and Vaccine Knowledge—were identified as significant contributors to the model. Notably, Impartial Beneficence emerged as the strongest predictor, with a standardized beta estimate of 1.94 (p < 0.001) and an odds ratio of 6.95. This indicates that higher levels of Impartial Beneficence are associated with a significantly increased likelihood of individuals opting for vaccine intake. Furthermore, the model’s explanatory power is underscored by the R²McFadden value of 0.47 and the Cox and Snell R² of 0.47, suggesting that approximately 47% of the variance in vaccine intake can be explained by the predictors included in the model. This level of explained variance is considered substantial, highlighting the importance of these factors in understanding vaccine intake behavior within the population studied.

Results for research question 2

Spearman’s matrix of correlations is presented in Tables 2 and 3.

Table 2 Logistic regression. Outcome variable: influenza vaccine intake

Table 3 Spearman’s coefficients matrix

The analysis revealed a significant association between vaccine knowledge and impartial beneficence, with a correlation coefficient of r(331) = 0.24, p < 0.001. Additionally, there was a notable association between instrumental harm and impartial beneficence, represented by a correlation of r(331) = 0.31, p < 0.001. However, no significant association was found between vaccine knowledge and instrumental harm, as indicated by r(331) = −0.09, p = 0.1, suggesting that these two variables are not related in this study’s context.

Discussion

In the context of this research, it is important to keep in mind a theoretical model that helps to make sense of the associations. The Cognitive-Affect Behavior (CAB) model and the Theory of Reasoned Action (TRA) are two theoretical frameworks that describe how cognition and affect lead to behavioral choices, including the decision to receive an influenza vaccine. The CAB model posits that cognitive beliefs and affective associations work together to influence behavior, such as vaccine uptake [49]. In the context of influenza vaccination, affective associations can mediate the effects of cognitive beliefs on vaccination behavior, serving as a form of “cognitive shorthand” that allows for quicker and more efficient decision-making about whether to get vaccinated.

The TRA, on the other hand, suggests that influenza vaccination behavior is primarily determined by an individual’s intention to get vaccinated, which is influenced by their attitudes (beliefs and values about the outcome of vaccination) and subjective norms (perceived social pressure to get vaccinated) [50]. It is important to note that the inclusion of affective components can enhance the explanatory power of these models in predicting flu vaccination rates. For instance, studies have found that affective associations can have a direct effect on attitudes and behavioral decisions regarding influenza vaccination, independent of outcome-specific cognitions [51]. This suggests that a comprehensive understanding of behavioral choices, such as the decision to receive an influenza vaccine, should consider both cognitive and affective factors, as well as their interplay in influencing vaccination rates.

This is especially important in the context of understanding the relationship between moral beliefs and actions. Recent research suggests that moral beliefs themselves may have limited direct motivational force in driving behavior. A study by Díaz [52] found that when stakes are high, the association between participants’ moral beliefs and actions is often explained by co-occurring but independent moral emotions, rather than the beliefs themselves. This finding supports the philosopher David Hume’s perspective on moral motivation, which posits that beliefs alone are insufficient to motivate action [53].

The connection between moral beliefs and behavior is further complicated by the fact that individuals often hold multiple, sometimes conflicting, moral beliefs simultaneously. In real-world situations, people may need to prioritize certain moral principles over others, leading to actions that might not align perfectly with any single moral belief. This process of moral decision-making involves weighing various factors, including potential consequences, social norms, and personal values, which can result in behavior that seems inconsistent with stated moral beliefs [54].

Moreover, situational factors play a significant role in determining whether moral beliefs translate into corresponding actions. Research in social psychology has demonstrated that external pressures, such as authority figures or peer influence, can lead individuals to act in ways that contradict their professed moral beliefs [55, 56]. The famous Milgram obedience experiments and Stanford prison experiment highlight how powerful situational forces can be in shaping behavior, often overriding personal moral convictions [57].

Given that the present study relied on the Oxford Utilitarianism Scale as the main measure of moral traits, it is important to briefly consider the most important findings of previous research applying this scale. Studies using the scale have revealed significant differences in how people approach morality along the dimensions of impartial beneficence and instrumental harm. [58] found that these two subscales measure distinct psychological factors that are inversely associated with various traits. For instance, high scores on the impartial beneficence subscale were associated with greater levels of trait empathic concern and lower levels of psychopathy, while high scores on the instrumental harm subscale correlated with decreased empathic concern and higher levels of psychopathy [59].

Körner et al. [60] demonstrated that the preference for utilitarian solutions in moral dilemmas is driven more by a reduced sensitivity to norms rather than an enhanced focus on consequences. This finding aligns with the observed correlations between OUS scores and psychopathy levels. Specifically, a high score on impartial beneficence scale correlates with a low level of psychopathy, while a high score on the instrumental harm scale is indicative of a high level of psychopathy. These results suggest that individuals who endorse impartial beneficence may be more empathetic and norm-sensitive, while those who accept instrumental harm may have reduced sensitivity to moral norms.

In the present study, impartial beneficence likely predicted willingness to get vaccinated against influenza more strongly than instrumental harm due to its focus on promoting the greater good and equal consideration for all individuals’ well-being. Individuals scoring high on impartial beneficence tend to prioritize actions that benefit the most people, even at a personal cost [61]. Vaccination aligns with this principle as it not only protects the individual but also contributes to herd immunity, thereby safeguarding vulnerable populations and the community at large.

Furthermore, the association between impartial beneficence and higher levels of empathic concern may explain its stronger predictive power for vaccination willingness. Empathy and concern for others’ well-being are key factors in motivating prosocial health behaviors like vaccination [62]. In contrast, instrumental harm, which is associated with lower empathic concern and higher psychopathy, may not align as closely with the altruistic nature of vaccination, which primarily aims to prevent harm rather than cause it for a greater good.

Previous research on utilitarian moral psychology has focused on subjects’ willingness to do some harm in order to maximize utility. This has been the approach of most trolley problem experiments [63,64,65,66]. However, Kahane et al. explain that these models have erroneously assumed that utilitarianism psychology operates solely along this dimension. That approach “ignores the positive, altruistic core of utilitarianism, which is characterized by impartial concern for the well-being of everyone, whether near or far” [46]. For that reason, the authors explain that utilitarian psychology must be approached from a bidimensional model that includes instrumental harm and impartial beneficence.

Additional studies have documented that those two dimensions are only loosely correlated [67, 68]. Those results are reproduced in this study. There is only a weak correlation between impartial beneficence and instrumental harm. This is another indication that utilitarianism in psychology cannot be studied as a single dimension. Previous studies show that the correlation between the two dimensions is higher amongst people involved in academic philosophy [69]. Such hypothesis was not tested in this study, as the inclusion criteria for the sample was being a university student of any major.

Instrumental harm has a statistically significant effect on the decision to receive the influenza vaccine shot, although not a very large one. This is partly expected. In any vaccination campaign, side effects are always bound to happen, and occasionally they may be lethal. Deaths following vaccinations do occur; although it is difficult to establish that they are due to vaccines themselves [70], at least in some cases, they can be attributed to vaccines. But by any reasonable calculation, the benefits outweigh the risks (even admitting that the risk is not zero). This is a utilitarian calculation that amounts to a tolerance of harm for the greater good. Consequently, it is expected that participants who realize the importance of influenza vaccine shots, are willing to have greater tolerance for harms in order to achieve a greater good. However, in the case of vaccine deaths, the harm is merely foreseen, but not intended. This is morally authorized by the non-utilitarian doctrine of double effect [71, 72]. The harm from vaccines is not strictly instrumental, as the unfortunate effects are not used as a means to an end; they are merely foreseen but unintended side effects. Nevertheless, even if not utilitarian in a full sense, the decision to accept the vaccine shot and accept its risks does correlate with greater display of utilitarian moral traits in the instrumental harm dimension.

However, in the logistic regression model, the effect of impartial beneficence was considerably greater than the effect of instrumental harm. This is very much expected. Individuals do not strictly need to be vaccinated in order to be protected against the influenza virus, because they can enjoy the benefits of herd immunity [73, 74]. However, this elicits the problem of free riding [75, 76]; an excess of free riders makes the herd immunity collapse, and this in turn brings about serious moral shortcomings.

Consequently, an individual may reason that he or she may not need to be exposed to the risk of vaccines, because herd immunity can protect him/her. How, then, do people make the decision to be vaccinated? Utilitarian psychology plays a major role. But this time, the decision does not come from the intent to instrumentally harm someone so as to bring about a greater good, but rather, the intent to extend beneficence to all, regardless of proximity to the individual. The decision to be vaccinated is twofold: it serves as individual protection, but it also serves as a contribution to the collective, even if such persons may not be directly known to the individual. There is an element of altruism in decisions to vaccinate. This has been especially studied in the case of influenza vaccine programs. In one study, it was concluded that “altruism significantly shifted vaccination decisions away from individual self-interest and towards the community optimum, greatly reducing the total cost, morbidity and mortality for the community” [77]. In another study, the authors state: “results suggest that pro-vaccine messages targeting altruism can increase vaccination intentions” [78], and in the recent pandemic, another study states that “triggering altruism increases the willingness to get vaccinated against COVID-19” [79].

This correlates well with the dimension of “impartial beneficence” from the OUS. Items from that dimension (e.g., “From a moral perspective, people should care about the well-being of all human beings on the planet equally; they should not favor the well-being of people who are especially close to them either physically or emotionally”) express the idea that there is a moral obligation to extend beneficence to as many people as possible, regardless of their proximity (physical, kin relation, etc.). In the case of vaccination programs, that implies making a contribution to herd immunity by assuming the small risk of side effects, all with the ultimate goal of protecting the collective as a whole, regardless of whether or not the potential beneficiaries are personally close.

Previous research has made much of the role knowledge plays in determining whether a person approves of receiving a vaccine shot [80,81,82,83]. This is based on the premise that the refusal to take a vaccine shot comes from disinformation about how vaccines work, and the conspiratorial mindset that has typically accompanied vaccine skepticism ever since the first vaccines were developed.

The same pattern is observed in the present study. In the regression model, vaccine knowledge served as a statistically significant predictor of acceptance of the influenza vaccine. In the UAE, public health authorities have gone a long way to implement educational programs so as to increase vaccine acceptance [28, 84,85,86], and it is expected that the success of these programs will ultimately have an impact on the curbing of influenza vaccine hesitancy.

Yet, it is important to point out that in the regression model, vaccine knowledge has a greater effect than instrumental harm, but a smaller effect than impartial beneficence. This resonates with philosophical approaches that emphasize the need for moral education and development. Knowledge of facts about the world is not enough to support proper action. Ethical dispositions are also needed, and that is the whole point of moral education. In order to prepare people to receive vaccine shots, certainly proper educational programs to dispel myths and transfer knowledge about vaccines are necessary. But a development of moral character so that people are prepared to embrace ethical responsibilities is also crucial. Althof and Berwokitz persuasively make the case that any society “must concern itself with the socialization of its citizens… citizenship education necessarily entails character and moral formation… the role of schools in fostering the development of moral citizens in democratic societies necessitates focus on moral development, broader moral and related character development, teaching of civics and development of citizenship skills and dispositions. Moreover, these outcomes overlap and cut across the fields of moral, character and citizenship education” [87]. The results of the present study suggest that in vaccination campaigns, these moral dispositions are more relevant than technical knowledge about vaccines themselves.

Educational authorities in the UAE have long understood the relevance of moral education and it has been properly inscribed in the curricula of many school programs [88, 89]. However, given the traditional values that prevail in this conservative society, there may be some resistance to openly transmit utilitarian values to pupils. Traditionally, religiously conservative scholars have expressed staunch opposition to utilitarian ethics [90,91,92,93]. But as explain in their development of the OUS, this largely rests on a misunderstanding, as negative assessments of utilitarianism are frequently based on the dimension of instrumental harm, leaving aside any consideration of impartial beneficence. In fact, Kahane et al’s research shows that increased acceptance of impartial beneficence is correlated with high religiosity. This finding may adequately inform the approach of UAE authorities, so that moral education can incorporate substantial aspects of utilitarian reasoning, and yet remain religiously conservative. The ultimate effect of this approach may very well be a greater acceptance of the seasonal influenza vaccine.

Limitations

One the major limitations of this study lies in its reliance on data collected exclusively from university students in the United Arab Emirates (UAE). This specific demographic may not adequately represent the wider population, especially when considering age-related differences in vaccine perception and moral reasoning. Consequently, the findings may be difficult to generalize to other age cohorts, such as children or older adults, who may have distinct attitudes and motivations regarding vaccination. Future research could benefit from broader participant samples that include diverse age groups to enhance the applicability of the results across different segments of the population.

Additionally, it is important to acknowledge that the intention to get vaccinated was self-reported by participants, which may introduce biases related to social desirability or inaccuracies in self-assessment. To strengthen future studies, it would be beneficial to incorporate objective measures, such as hospital data that verify actual vaccination status against reported intentions. This approach would provide a more accurate understanding of vaccine uptake and create a more robust framework for evaluating the effectiveness of interventions aimed at reducing vaccine hesitancy. Integrating such comprehensive data could yield valuable insights into the motivations behind vaccination decisions and inform public health strategies more effectively.

Conclusion

Some important conclusions can be obtained from the study. First, the study serves to confirm [46] the insight that utilitarian psychology cannot be properly understood as unidimensional. More importantly, the study sustains the notion that utilitarian psychology may in fact serve to protect people against seasonal influenza vaccine hesitancy. This effect is twofold: greater tolerance for instrumental harm implies greater tolerance of the minor risks that may be incurred by vaccination; but more importantly, greater commitment to impartial beneficence implies greater motivation to receive the seasonal influenza shot, presumably due to the understanding that herd immunity is needed and beneficial for the collective.

For purposes of public policy as applied in the UAE, this study also offers some important conclusions. While health literacy and technical knowledge about how vaccines work certainly play a role in curbing seasonal influenza vaccine hesitancy, this study reveals that the moral approach may be even more important.

This has important educational and communicational implications. While proper moral education must be organic and it is not advisable for educators to impose doctrines on pupils (especially if they are open to debate, such as utilitarianism), it must still be reckoned that utilitarianism is a respectable ethical doctrine, and consequently, it should shape some of the contents that are delivered in moral education programs. Scholars have long advised the introduction of utilitarian notions in moral education [94,95,96,97,98].

The justification for this recommendation typically rests on notions of democracy, nation-building and civility. By teaching students to consider the consequences of their actions on the overall well-being of society, utilitarianism fosters a sense of civic responsibility and social cohesion. This approach encourages individuals to look beyond their personal interests and consider the broader impact of their choices on the community as a whole, which is crucial for building a unified and prosperous nation.

The utilitarian motto—originally attributed to John Stuart Mill— “everybody to count for one, nobody for more than one” encapsulates the philosophy’s commitment to equality and impartiality, which are essential principles for nation-building [99]. This concept aligns with the work of scholars of liberalism and multiculturalism such as Will Kymlicka; his research on citizenship and diversity complements utilitarian thinking by emphasizing the importance of equal consideration for all members of society, regardless of their cultural background [100]. By incorporating these ideas into moral education, nations can foster a sense of shared identity and purpose among diverse populations, promoting social harmony and collective progress towards common goals.

A further relevant conclusion from this study is that the introduction of utilitarian reasoning in moral education in the UAE may even have additional epidemiological benefits. To the extent that pupils are presented with the ethical advantages of utilitarianism and their moral reasoning consequently reflects this trend, they will be more motivated to receive the seasonal influenza shot, and thus curb the spread of a disease that, while not an extreme concern in the UAE, still presents a challenge to health authorities [101].