The widespread application of Human Enhancement in terms of the specific vaccination against SARS-CoV-2 provides an excellent opportunity to study reservations against vaccination as such in the context of the ongoing ethical debate about Human Enhancement. First of all, it is crucial to carve out the divergence between the public perception of vaccinations as Human Enhancement and the academic discussion of this phenomenon. As in another study [4], those phenomena that, at first glance, represent a combination of invasiveness and some kind of technological device (cybernetic prostheses and cochlear implants) were considered to be the best example of Human Enhancement. Other examples frequently discussed in the literature were not seen in such an exemplary way. There are many different conceptualizations of Human Enhancement [14]. Accordingly, functional approaches emphasize how technologies can improve an existing capability of the human body. Under this and other notions, vaccination is indeed Human Enhancement. Further research should investigate which conceptualization of Human Enhancement is publically predominant. Our findings substantiate the impression that Human Enhancement is publically understood and defined in terms of invasiveness and the material presence of the technology in question. Factors that also influence the acceptance of such technologies [15].
People are less likely to use cognitive enhancement methods when considered invasive, even when told that no adverse side effects are expected. Perceived naturalness, higher attitude toward Human Enhancement, being vaccinated against SARS-CoV-2, and low application frequency increase the willingness to use means of a cognitive enhancement. The role of naturalness and invasiveness is concurrent with other studies [15–S17][2]. Among individuals not vaccinated against SARS-CoV-2, perceived naturalness was more influential than among vaccinated participants.
Our sample is clearly divided by the attribute of being vaccinated against SARS-CoV-2. Vaccinated and unvaccinated people differ in nearly all parameters that we have tested. Most importantly, unvaccinated people show a higher attitude towards naturalness and report attitudes favoring phenomena commonly associated with alternative medicine and disfavoring those that imply a human interference with nature.
At the end of the study, nearly 85% of German adults had received at least one dose of vaccination against SARS-CoV-2 [10]. Reasons for vaccine hesitancy before or at the start of the vaccination campaign might have been grounded on concerns about safety and efficacy [18, 19]. Today, more than a year later (vaccination in Germany started in December 2021) and like in many other countries (e.g., Austria ~ 25%, Hungary ~ 35%. Italy ~ 15%, USA ~ 18% unvaccinated [20, 21], there are still people who reject vaccination. In addition to the aforementioned reasons, reasons to reject any vaccination against SARS-CoV-2 may reside in the fundamental objection against any invasive technological intervention deemed unnatural.
Table 9
Excursus: Empirically found parallels in reasons for the negative attitude toward and the reluctance of Human Enhancement and vaccination
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Naturalness
It has been found that people are more reluctant to use cognitive enhancement if unnatural or that concerns about unnaturalness and purity are reasons for rejecting these enhancements [16, 17, 22]. Naturalness bias or the belief that natural immunity is superior to vaccination are hindering factors for vaccination intention and behavior [23–26], although laypeople can show a different notion of what naturalness means in the context of certain vaccinations [3].
Safety and efficacy
People express concerns about adverse side effects of (cognitive) enhancement and are less likely to use it if these are expected or severe [27–31]. Negative side effects are one major reason for a critical attitude towards vaccinations [18, 19, 25, 32, 33]. People are more likely to use a cognitive enhancement if the improvements are great and reliably expectable [31]. Doubting the effectiveness of vaccines negatively influences vaccination intention and behavior [18, 19, 25]. On a more philosophical level, critics of Human Enhancement fear backfiring and disastrous side effects such as alienation from our not enhanced peers and the world, losing what makes us human, or sealing the end of our species [34–38].
Invasiveness
People are less likely to use an enhancement if the method is invasive [15–17]. Invasive application of vaccines by injection can trigger the fear of needles and hinder vaccination efforts [39].
Fairness
When discussing the moral acceptability of Human Enhancement, fairness plays a role [17, 22, 27, 40], but see also 28 [28]. Besides the global availability of vaccinations [41], fairness in the context of vaccination against SARS-CoV-2 is especially important when considering immunity privileges [42, 43].
General
There are many similar concerns regarding vaccinations that can be found in the general debate about Human Enhancement. This is not surprising since both phenomena generally aim to intervene with the individual body and directly concern important aspects such as bodily autonomy, health, and the relationship to nature and technology. It is important to note that many studies only assess moral acceptability and willingness regarding cognitive enhancement. This is just one subfraction of Human Enhancement. Studies also often examined moral permissibility in hypothetical scenarios. More research is needed to examine how moral judgments about various enhancements translate into factual behavior.
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Suppose vaccine skepticism reflects strong core beliefs about the association between agency, nature, spirituality, and individual health [44], it is reasonable to assume that the same motives underlie aversion to human enhancement (Table 9). Yet, it is questionable if unvaccinated participants understand Human Enhancement as improvement in the first place. Just as they may see vaccination against SARS-CoV-2 as a risky, unnatural, and consequently unbearable intervention, adverse side effects of other instances of Human Enhancement may weigh out their promised benefits. Following this rationale, low ratings and the not evident differences in classifying phenomena as Human Enhancement may be due to two different reasons. While vaccinated people may apply a different definition of technology or question if prevention is an enhancement [45], unvaccinated people may additionally question if any unnatural intervention can constitute the improvement implied by Human Enhancement. Naturalness plays a role in accepting means for Human Enhancement [16, 17, 22]. Vaccination behavior and intention are hindered by concerns about naturalness and the belief that natural immunity is superior to vaccinations [23–26]. Hence, naturalness seems to have a different salience for unvaccinated people. We can see this in the moderation effect of perceived naturalness on the willingness to use an enhancement. If something natural is automatically “good,” it seems likely that something unnatural is considered “worse,” i.e., cannot improve oneself.
Interestingly, enhancement ratings of unvaccinated participants differed in two cases, extensively covered by the literature as prime examples of Human Enhancement: Drugs to increase life expectancy and drugs to enhance cognitive functioning. These enhancements are considered crucial for the “Enhancement Project” and the desire to radically emancipate from the human condition [7, 34, 46]. While there are reasons to reject radically enhanced cognitive functions based on a “conservative bias” that values the status quo more than a promised, more valuable future condition, radical life expectancy enhancement cannot be rejected on the same ground [47].
The data shows that attitudes toward naturalness negatively influenced attitude toward vaccination for both unvaccinated and vaccinated participants, although it was more influential for unvaccinated participants. In addition, attitudes toward human enhancement only increased attitudes toward vaccination for the unvaccinated group (Fig. 4, upper right panel). This finding shows that unvaccinated participants tend to be more favorable to a specific biotechnological intervention when they are generally open to the improvement of human capabilities. Yet, important to note that these beliefs seem not strong enough to convince people to get vaccinated.
Naturalness attitude mediated the effect of being vaccinated on attitude toward vaccination and Human Enhancement. Attitude toward Human Enhancement mediated the effect between being vaccinated and attitude toward vaccination, although at a lower percentage than naturalness attitude. The ambivalent predictive power of the rating of vaccinations as an example of Human Enhancement (only present in one model) and its non-existing mediation on the attitude toward vaccination imply that unvaccinated people’s aversion is not evoked solely by the label “Human Enhancement.” Instead, mediation effects of the naturalness attitude combined with the moderating influence of the attitude toward Human Enhancement and naturalness attitude substantiate the impression that unvaccinated participants deem vaccination and Human Enhancement unfavorable due to similar reasons. They do not reject vaccinations because they label them as Human Enhancement, but oppose both phenomena because they are unnatural (technological) interventions of the body. They do not conceptualize vaccinations explicitly as Human Enhancement. This reflects the difficulties of finding an appropriate definition of Human Enhancement and the utterly utopian, respectively, dystopian debate tone [14, 48].
Here, it is essential to note that interventions not commonly associated with “unnaturalness” may boost human performance and qualify as Human Enhancement under a specific definition [4, 14, 49]. Examples are instrumental music training [50], Tai Chi in combination with cognitive interventions [51], and even drinking water [52]. These means may be seen as “conventional,” “natural,” or “historical” and less problematic [8, 35, 53]. General difficulties with this prescription are discussed elsewhere [4, 9, 54]. Franke et al. [28] report that particpants expressed ambiguous opinions on morally equvalating caffeine and neuroenhancement drugs. Still, it is important how personal attitudes on naturalness can influence adaptation of technologies even when, as in the case of vaccinations, they have been conventionally used for about 300 years.
Effects of vaccinations are not only the objective protection against a deadly virus but also a differing relationship between oneself and the environment. Vaccinated over unvaccinated participants reported a significant improvement after the first dose of vaccine and more positive effects due to their vaccination status. The environment to which the vaccinated participants have adapted is perceived differently. In addition, these people feel technologically enhanced. However, one must note the low affirmation of this statement among vaccinated individuals and the possibility of a confoundation due to asking whether participants consider vaccinations as Human Enhancement.
Interestingly, vaccinated people, although better protected against the disease [55, 56], reported no differing feelings of vulnerability compared to unvaccinated people. In addition, unvaccinated participants reported being more relaxed. Two effects seem to be at work here: Most obviously, unvaccinated people seem not to view SARS-CoV-2 as dangerous. A general carelessness about the disease also explains why there are no differences between unvaccinated and vaccinated participants when asked if the disease appears less dangerous to them: If it is considered harmless, the perceived danger is hard to decrease. In addition, reports of decreasing immune protection combined with the dominance of B.1.1.529 (“Omicron”) in Germany may have fostered increased concerns among vaccinated people. Logically, those most concerned about their safety engage in the most protective behavior. However, it is unclear if the risk perception is phenomenological speaking comparable. Human Enhancement technologies transform the perception of risk [6], yet there may be profound disagreement between vaccinated and unvaccinated participants about the dimensions of risk posed by the virus.
Moreover, our data reveal the social components of Human Enhancement technologies. Disease containment measures to the disadvantage of unvaccinated people may have contributed to feeling left out and the adverse reactions from peers. Possible social influence, coercion and division are prevalent topics in the Human Enhancement debate [9, 30, 31, 35, 57–59]. Any so-experienced coercion to enhance, regardless of its origin, can directly interfere with the subjective notion of autonomy and bodily integrity. The sometimes violent and aggressive civic protest of opponents of disease control measures and vaccination can be interpreted as the counter-reaction to an augmented (vaccinated) social and political environment to which the unvaccinated do not want to adapt with the help of Human Enhancement. Indeed, the vast majority of unvaccinated people are not planning to get a vaccination in the future. If there is a sufficient supply of vaccines, every citizen is faced with whether or not to be vaccinated. The result of this collective interpellation may be an intense polarization. Therefore, whether to get vaccinated and the adjunct considerations about safety, efficacy, and the attitude toward nature must be viewed as the outcome of a socio-technological transformation of risk [6] that demands an individual decision. Besides concerns about safety and efficacy, there are political and naturalness-related dimensions of vaccine hesitancy and risk perception of the current SARS-CoV-2 pandemic [26, 60, 61] that may emerge again in future, possibly even more deadly epidemics. Therefore, vaccine hesitancy should not be seen as a purely individual matter but embedded in the socio-technological context and the resulting individual and societal relationship to nature and risk.
While the population of vaccinated persons is very heterogeneous simply by size, unvaccinated people show characteristics of a distinct population regarding their attitude towards nature and technological interventions. Odds ratio of wanting more doses when being vaccinated three times compared to zero doses was < 1 when also considering attitude toward vaccination, support of disease control measures, or naturalness attitude. This finding suggests that these variables are the primary drivers of the decision process of getting more doses when already boostered. If examined in a broad context of different variables, having received three doses alone is insufficient to predict further doses.
It is important to note two transition steps when predicting future vaccination doses. First is the decision to get vaccinated at all. Our data suggest that this is related not only to attitudes toward vaccination but also to the basic notion of what technological changes are considered acceptable and necessary and how they relate to nature. Once vaccinated, the second transition is the decision to get more doses of the vaccine, or more specifically, to plan to get as many doses as medically required or needed. Here, the impact of the individual set of beliefs and attitudes on naturalness-related questions decreases and can only be found if not considering other variables in the model. A high naturalness attitude seems to prevent people from getting vaccinated but not receiving more doses after being fully vaccinated. Any effect of naturalness attitude toward the probability of planning to get more doses may reside in the fact that the whole sample included unvaccinated participants, whose majority refused to get vaccinated (more doses) and showed a higher naturalness attitude than vaccinated participants. Wanting more vaccination among the vaccinated participants depends mostly on the attitude toward vaccination and the support of disease control measures. When predicting the exact number of planned vaccinations, it became evident that people with two doses seemed to plan until getting boosted. The already boostered partially plan even further and are ready to receive even more doses. This cannot be explained by the fact, that “more” for boostered patients is always more than three doses. These people can still refuse any further doses, yet often stated explicitly that they are willing to receive as much doses as needed. Once again, the support of disease control measures and the attitude toward vaccinations mattered the most here, while naturalness attitude had no predictive power. In addition, the positive aspect based on their vaccination status mattered only for people having received two doses. It is unclear whether the vaccinated persons are apodictic on their planned doses. Yet, it seems like there are psychological thresholds, ranging from dose to dose, that must be sequential traversed when planning further ahead.
The effect of attitudes toward vaccination and the support of disease control measures suggest two primary motivations here. First, one attitude toward vaccination may be grounded on having had good experiences and acknowledging the important effect of this technology in fighting the pandemic. Secondly, the support of disease control measures should not be interpreted as an end in itself but rather a reflection of the perceived danger of the virus. Besides questioning the general necessity, there are other reasons not to support measures like school closings and immunity passports. Still, if someone deems the virus not dangerous, they are less likely to support any countermeasures or get vaccinated [18, 26, 60, 62]. Another possibility may be that vaccinated want to receive more doses not primarily because they are convinced of their individual and public health benefits, but due to the restrictions imposed on unvaccinated and not boostered persons. Either way, getting boostered or vaccinated in the first place can be understood as the adaption of oneself to a hazardous or socially restrictive environment through technology, i.e., a form of Human Enhancement.
Limitations
There are several limitations to this study. With only ~ 15% of unvaccinated Germans above 18 years, those left may represent a specific ideological hard kernel. Hence, the generalizability of our findings to vaccine hesitancy in general, particularly at the beginning of a vaccination campaign, is limited. Unvaccinated participants were targeted using Facebook groups deemed critical to disease control measures. It is unclear if the members of the respective groups are representative of other unvaccinated participants. Moreover, only four participants reported having received only one dose. Therefore the transition between one and two doses deserves additional research.
While naturalness attitude seems to matter, we did not answer participants why they are not vaccinated. Therefore, the direction of the effects shown here remains unclear. We do not know if the attitude toward vaccination was already low before the pandemic or if the ubiquitous discussion of this issue has polarized vaccinated and unvaccinated. Further studies are needed to disentangle correlation and causation here.
Due to the timely nature of this research, the items we employed were not part of a preexisting psychometric instrument and should be further tested for their validity. Items making a direct reference to the effect of the vaccination are of limited use when answered by unvaccinated participants. Comparing the exact number of vaccinations is challenging due to differing regularities of required doses for licensed immunity. In addition, there may be some participants who cannot be vaccinated due to medical reasons or have just recovered from the disease. Lastly, the interventions when assessing the willingness to use a cognitive enhancement should be balanced and varied to a greater extent in future studies.
Footnote:
[2] Scheske and Schall [17] report mixed results on naturalness.