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The moral foundations of needle exchange attitudes

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The moral foundations of needle exchange attitudes

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The Moral Foundations of Needle Exchange Attitudes
by
Nina Christie

A Thesis Presented to the
Faculty of the Dornsife College Of Letters, Arts And Sciences
University of Southern California
In Partial Fulfillment of the
Requirements for the Degree
Master of Arts
PSYCHOLOGY

December 2019

i
Table of Contents

Abstract ……………………………...……………………………………………………………ii

Introduction ……………………………...…………………………………………..……………1

Methods ……………………………...………………………………………………………...….5

Results ……………………………...………………………………………………...…….……..9

Conclusion ……………………………...…………………….…….…………………………...14

Limitations ……………………………...………….……………….…………………………...17

References ……………………………...………….……………….……………………………20

ii
ABSTRACT:

Introduction: Needle exchange services reduce spread of disease. However, these services lack
public support, in part because of moral misgivings. Research suggests that moral attitudes are
grounded in at least five “foundations”: 1) Care, 2) Fairness, 3) Loyalty, 4) Authority, and 5)
Purity. Understanding the moral basis of needle exchange attitudes could inform public health
messaging.
Method: Participants (n = 5369) completed a questionnaire on needle exchange attitudes (NEA)
and also completed the Moral Foundations Questionnaire (MFQ).
Results: The NEA had high internal reliability. NEA was most strongly predicted (in the
negative direction) by individual level of Purity concerns followed by (in the positive direction)
Care concerns.
Conclusion: Moral Foundations Theory provides a framework for understanding moral attitudes
towards needle exchange. Moral misgivings about needle exchange are associated with Purity
concerns. If this association is causal, it may offer insight into how to build wider support for
needle exchange programs.

1
Introduction:
The societal, health, and economic harms associated with illicit drug use are high. “Harm
reduction” is a term used for a wide range of public health programs directed at reducing these
various costs in ways other than the direct promotion of abstinence. Offering new sterile
injection needles in exchange for used needles (“needle exchange”) is one such program. Needle
reuse and needle sharing are common among injecting drug users, leading to increases in the
spread of blood-borne diseases including HIV/AIDS and Hepatitis C. By providing sterile
injection equipment, often in conjunction with other harm reduction services, needle exchange
programs (NEPs) may reduce the adverse health impacts of IV drug use.
It is difficult to assess the effectiveness of NEPs. Comparisons between regions with and
without NEPs, or of the same region before and after the introduction of an NEP always include
a myriad of uncontrolled factors. Both the potential value of the programs (e.g. reduced spread of
HIV) and the potential risks skeptics worry about (e.g., increased drug use) require long study
periods. However, we are now more than three decades out from the first needle exchange
program (for early history see Buning, 1991), and there have been more than a dozen reports
assessing outcomes (Abdul-Quader et al., 2013; Strathdee et al., 2010; Vlahov, Robertson, &
Strathdee, 2010). While none has the probative value of a large randomized double-blind clinical
trial, the collective accumulation of evidence makes a convincing case for the value of these
programs. The most recent large meta-analysis of which we are aware concluded that there was
indeed statistical evidence that NEPs lead to a reduction in the transmission of HIV (Aspinall et
al., 2014). Moreover, no evidence of increased IV drug use has yet emerged (Fisher, Fenaughty,
Cagle, & Wells, 2003). Currently these programs are endorsed and encouraged by public health
organizations including the National Institute of Health (Knopf, 2015), the Center for Disease
Control and Prevention (Wejnert, 2016) and World Health Organization (WHO, 2004). In
2
December of 2016, the US Surgeon General called for the expansion of these programs, citing
them as “cost-effective prevention strategies that have been shown to reduce the transmission of
HIV in communities implementing them, without increasing rates of injection drug use.”(Surgeon
General US, 2016).
Yet, needle exchange programs remain controversial in the US. The collective
ambivalence over these programs is evident in the past thirty years of relevant legislation,
beginning with the ban on federal funding enacted within the 1988 Health Omnibus Programs
Extension (HOPE) Act (Kennedy, 1988). The ban was lifted twenty-one years later (Olver,
2009), only to be reinstated in 2012 (Culberson, 2011). Recently, in response to the opioid
epidemic, there was a partial lifting on the ban, making it again lawful to direct federal support to
needle exchange programs with one proviso; federal money going to needle exchange programs
cannot go to the actual purchase of needles (Dent, 2015).
The back-and-forth of needle exchange funding restriction has generally been in step with
political trends, with periods of left of center government favoring federal funding, and right of
center government favoring prohibition on funding. Expressing conservative opposition to NEPs,
The Hoover Institute’s Joseph Loconte argued that for the welfare of all involved, including the
IV drug user, it was time “to stop medicalizing what is fundamentally a moral problem.
Treatment communities that stress abstinence, responsibility, and moral renewal, backed up by
tough law enforcement, are the best hope for addicts to escape drugs and adopt safer, healthier
lifestyles.”(Loconte, 1998). In a speech given at the UN in response the organization’s support of
NEPs, Archbishop Francis Chullikatt of the Catholic Church objected, “Such efforts do not
respect the dignity of those who are suffering from drug addiction as they do not treat or cure the
sick person, but instead falsely suggest that they cannot break free from the cycle of addiction.
3
Such persons must be provided the necessary spiritual, psychological and familial support to
break free from the addictive behavior in order to restore their dignity and encourage social
inclusion.”(Chullikatt, 2011).
Although the above suggests moralization of needle exchange is particular to
conservative opposition, an alternative interpretation of the controversy is that disagreement is
less over whether moral arguments are used than it is over which moral arguments are used. As
epidemiologist A. R. Moss put it, “Liberals are accustomed to thinking it is conservatives who
employ moral crusades... But getting AIDS research and treatment funded in the United States
was also a moral crusade, driven by gay activism and powered by the idea that stigmatization
should not prevail. It was because it was a moral crusade that the movement to make AIDS a
fundable disease on a par with cancer or heart disease was successful.”(Moss, 2000). Similarly,
in their discussion of sixteen years of parliamentary debate over NEPs in Sweden, Eriksson and
Edman (2017) concluded that moral arguments (rather than scientific evidence) dominated both
sides of the debate. Understanding the nature of moral views on NEPs may bear insights for
those interested in building acceptance of the programs.
Within moral psychology, there has been growing support for a pluralistic framework
called Moral Foundations Theory (MFT) (Graham et al., 2013; Haidt, 2001; Haidt & Joseph,
2004). According to MFT, humans evolved several distinct motivational mechanisms that can
guide social behavior. These motivations are leveraged to different degrees by different cultures.
Some may be ignored or even rejected by a person or culture, but each is thought to be a
“prepared” human social motivation, in that it is easy to cultivate given relatively little
encouragement. MFT suggests at least five such “foundations”: 1) Care (possibly grounded in
the protracted parenting required to raise a child; a sample Care item on the Moral Foundations
4
Questionnaire (Graham et al., 2011) asks the moral relevance of, “Whether or not someone cared
for someone weak or vulnerable”), 2) Fairness (possibly grounded in the ‘tit-for-tat’ motivations
that facilitate human cooperation; a sample Fairness item asks about agreement with the
statement, “Justice is the most important requirement for a society.”) , 3) Loyalty (possibly
supporting human capacity for enduring alliances; a sample Loyalty item asks the moral
relevance of, “Whether or not someone did something to betray his or her group”), 4) Authority
(possibly supporting group cohesion through hierarchical organization; a sample Authority item
asks the moral relevance of, “Whether or not an action caused chaos or disorder”) and 5) Purity
(likely rooted in motivation to protect the body from contamination, but generalized to protection
of the self from moral contamination; a sample Purity item asks the moral relevance of,
“Whether or not someone did something disgusting”). The 32 item Moral Foundations
Questionnaire yields a summary score for each of these five domains (Graham et al., 2013;
Haidt, 2001; Haidt & Joseph, 2004). MFT is entirely descriptive in nature, which is to say it
takes no position on whether any or all of the foundations should impact moral judgments. MFT
only claims that the distinct foundations do impact judgment, to varying degrees (Graham et al.,
2011; Graham, Haidt, & Nosek, 2009; Haidt, 2001; Haidt & Joseph, 2004; Koleva, Graham,
Iyer, Ditto, & Haidt, 2012).
MFT research suggests that moral disagreement between individuals or between cultures
is often related to differences in the weighting of moral foundations (Haidt & Joseph, 2004).
Perhaps the most robust finding to date is that liberal secular sub-cultures in the West emphasize
the Care and Fairness foundations, and de-emphasize the other foundations, while more
traditional and conservative sub-cultures show more equal emphasis across the five foundations
(Graham et al., 2009). MFT has been used to clarify the nature of moral disagreements over gay
5
marriage, euthanasia, abortion, pornography, stem cell research, and mandatory vaccine
programs (Amin et al., 2017; Clifford & Jerit, 2013; Koleva et al., 2012). Moral disagreements
are often at the root of issues that cannot be remedied with facts alone.
According to the theory, Moral Foundations drive rapid and automatic associative
processes that happen outside awareness. On this “moral intuitionist” conception (Haidt, 2001),
the affective core of a moral judgment usually arrives into conscious awareness already largely
solidified. Importantly, since the driving associative processes are not conscious, people may
have difficulty justifying their moral intuitions. In some cases, the explanations people give are
demonstrably not the actual drivers of the intuition (Haidt, 2001). That is, conscious processing
may begin with an intuitive moral judgment, and be followed by a search for reasons that support
the intuition. This is important in relating MFT to needle exchange attitudes because it suggests
that moral arguments should not be taken (or at least not only taken) at face-value.
Moral Foundations Theory may provide a useful framework for approaching the topic.
Here we take initial steps along this path, first in developing a brief questionnaire to measure
attitudes towards needle exchange programs, and second by assessing the association between
needle exchange attitudes and individual differences in moral foundation endorsement. We are
interested in which foundations are most strongly associated with attitudes towards needle
exchange programs. These foundations can be considered promising candidates for underlying
drivers of attitudes.
Method:
We developed a seven-item questionnaire to measure needle exchange attitudes (NEA)
and related services (see Appendix 1 for the full scale). The content of the items was based on
resources available at a particular Los Angeles program, Homeless Health Care Los Angeles
6
(HHCLA), which are similar to those offered at other facilities in the US. Resources available at
this facility include sterile injection equipment, condoms for safe sex practices, and naloxone (a
drug that blocks opioid receptors and stops overdoses to prevent them from becoming lethal).
Although we did not carry out extensive scale development work, we do report basic
psychometric analyses of the scale in order to inform interpretation of our data set.
We collected data on both NEA and MFQ as well as demographic information on 5,434
participants using the YourMorals online platform (YourMorals.org), a data collection platform
where, after providing basic demographics, participants are invited to take part in any of 30–40
studies, each described with a title and a brief one sentence description. The needle exchange
survey was titled, “Harm Reduction Attitudes”, and described as, “How do you feel about
reducing the harm associated with drug use?” Participants are free to take part in any or all
surveys on the site. People who use this platform have the option to complete the moral
foundations questionnaire when they create a profile, so we are able to collect data on needle
exchange attitudes for people who have existing profiles and who have already taken the Moral
Foundations Questionnaire. Participants voluntarily completed study measures and were not
compensated. After completing each questionnaire, participants were provided a description of
the measure and were shown a graph of how their scores compared with others. We opened
access to the questionnaire on Dec 5 2017 and included all participants that completed the
measures (NEA and MFQ) at the time we began data analysis used in this report (May 21, 2018).
Completion times for the seven item NEA questionnaire were recorded, and participants
that spent less than 30 sec completing the 7-items were excluded from the report. As with
convenience samples generally, the participating population is not representative of the general
population. From past publications using data from this source, we anticipated that the US
7
participants would skew liberal, male, young, and higher in years of formal education relative to
the US population(Glenn, Koleva, Iyer, Graham, & Ditto, 2010; Graham et al., 2011; Koleva et
al., 2012). Participants usually find YourMorals.org through publicity about psychological
research, or by searching for keywords related to morality in a search engine. Response patterns
on the MFQ are similar for participants from diverse referring sources (Iyer, 2009). All measures
acquired for this study are included in this report, with the exception of an open ended question
that read, “Please let us know any general views or beliefs you have that informed your answers
to the above questions.” Responses to this open-ended question have not been analyzed at the
time of this report. All data used in this report has been made freely available in the Open
Science Framework at: https://osf.io/cvftn/
Primary analyses
Approximately 1.2% of participants (n = 66) were dropped due to completion times of
less than 30 seconds. The median completion time for the removed participants was 9.0 sec, and
for retained participants it was 110.6 sec. NEA questionnaire data from the retained participants
(N = 5369) were subjected to a factor analysis, as well as assessment of internal reliability. Next,
multiple regression was used to examine the degree to which NEA responses could be predicted
based on the five foundation scores. We carried out this regression first on the NEA scores, and
then on residuals from a model predicting NEA from several participant characteristics including
political identification and religious affiliation. Finally, we investigated whether observed
associations between moral foundation scores and NEA differed as a function of political
identification. Given the large sample, emphasis is placed on effect size rather than significance
testing. However, where significance testing is discussed, a is set to .005 (Benjamin et al., 2018).
8
Our sample provided power at 1-B=.8 to detect predictor variables that explain 0.25% of
variance with a = .005.
Sample Demographics
Participant demographics are presented in Table 1. As can be seen, the sample was
majority male, highly educated, and tended towards political liberalism. Approximately 2/3 of
the sample were from the US.
Sample Demographics & Needle
Exchange Attitudes

NEA Score
NEA Association
Statistic
Age 36.2 + 14.6
- r (5369) = .079
Socioeconomic
Status (1-10) 6.33 + 1.78

-

r (5369) = .027
Sex
Male
Female
70.8%
29.2.%

5.32 + 1.27
5.52 + 1.28
F (1,5367) = 23.7
Country
USA
Canada
UK
Other
67.0%
6.6%
5.6%
21.8%

5.31 + 1.31
5.55 + 1.27
5.53 + 1.22
5.55 + 1.12
F(3,5365) = 13.5
Education
College/graduate degree
or in college
Less than college
83.0%
17.0%

5.41 + 1.23
5.28 + 1.34
F(1,5367) = 18.6
Political Identification F(9,5359) = 255.1
Very Conservative 2.3% 3.26 + 1.26
Conservative 8.1% 4.12 + 1.33
Slightly Conservative 8.4% 4.67 + 1.23
Moderate 13.5% 5.32 + 1.10
Slightly Liberal 12.8% 5.67 + 0.95
Liberal 23.2% 6.02 + 0.80
Very Liberal 9.2% 6.38 + 0.71
Libertarian 14.8% 5.16 + 1.27

Not political/Don’t
Know 3.6%
4.83 + 1.17
Other 4.1% 5.36 + 1.37
Religion
F(10,5358) = 75.9
Decline to Respond 5.1% 4.83 + 1.17
Agnostic 16.3% 5.54 + 1.14
Atheist 27.2% 5.84 + 1.01
Buddhist 1.5% 5.78 + 1.14
Christian 25.2% 4.66 + 1.40
Hindu 0.4% 5.00 + 1.33
Islam/Muslim 0.9% 4.84 + 1.29
Jewish 1.6% 5.55 + 1.12
No particular religion 8.4% 5.39 + 1.23
Other 2.5% 5.45 + 1.26
Spiritual only 11.0%
5.58 + 1.14
Table 1: Sample demographics and relation to needle exchange attitude. For presentation,
country and education are collapsed into fewer categories than available to participants.

9
RESULTS:
Scale Assessment

A principal component factor analysis was carried out for our 7-item needle exchange
program questionnaire. Results indicated just one component with an Eigenvalue greater than
one; this factor accounted for 56.9% of the variance within the sample. Inspection of the scree-
plots suggested no justification for incorporating a second factor in subsequent analyses for
either sample. Cronbach’s Alpha for the scale was .87, (a = .87 in the US participants and a =
.85 in non-US participants). Removing any single item resulted in a lower Cronbach’s Alpha (see
Table 2). Based on the strong support for scale coherence around one factor, the mean of the 7
items (with reverse coding of the two items worded so that agreement indicated negative
attitudes) was used in all subsequent analyses.

Relation between demographic factors and needle exchange attitude
Within our sample, attitudes were generally favorable to needle exchange (mean 5.39 + 1.28 on
the 1-7 scale). Only 14.2% (760 participants) had mean item scores below the scale midpoint of
4. A total of 37.2% of the sample had a mean item score over 6, and 7.2% of participants (387
participants) gave all items the most favorable rating.
10

Females had slightly more favorable attitudes towards needle exchange than did males
(5.52 vs. 5.33 on the 7 point scale (t(5367) = 4.87, p <.001; eta
2
= .004). There was a slight
tendency for older participants in the sample to express more positive attitudes towards needle
exchange (r(5369) = .079, p <.001). Socioeconomic status was not associated with NEA r(5205)
= .027, p = .055.
Since some education responses could not be clearly placed on a single ordinal scale
(e.g., “Currently enrolled in university”), we treated the education variable as categorical in our
assessment of its relationship to NEA. Using univariate ANOVA, education significantly
predicted NEA (F(9,5359) = 6.99, p < .001) but the effect size was small (partial eta
2
= .012). In
general the relationship was driven by more positive attitudes among individuals with more
education. NEA also differed across religious affiliation (F(10,5358) = 75.88, p < .001; partial
eta
2
= .124) with Christians expressing the least favorable NEA (4.66 + 1.40) and atheists the

Mean SD
Corrected
Item-Total
Correlation
Cronbach’s
Alpha if Item
is Deleted
Question (Paraphrased – see
Appendix 1 for full scale)
Is it a good idea to reduce disease
using NEPs?
5.65 1.67 0.80 0.83
Is it a good idea to provide
naloxone at NEPs?
5.34 1.78 0.55 0.86
Do NEPs effectively reduce
disease?
5.98 1.37 0.63 0.86
Is it a good idea to supply
condoms at NEPs?
5.91 1.57 0.61 0.86
Do you support NEP in your
area?

5.05 1.94 0.77 0.83
Do NEPs increase drug use
overall? (R)
5.11 1.69 0.59 0.86
Do NEPs make using drugs seem
okay? (R)
4.67 1.87 0.60 0.86
Total 5.39 1.28
*R = reverse coded
Table 2: Mean, standard deviation, and scale assessment measures the correlation of the item
with the total attitude score and the Cronbach’s alpha if each item was to be dropped (overall
Cronbach’s alpha = .87). Questions here are paraphrased from the survey for brevity, for full
scale see Appendix 1.

11
most favorable (5.84 + 1.01). We also observed a strong relationship between political
identification and NEP attitudes F(9,5359) = 255.06, p < .001; Partial eta
2
= .30). Broadly, more
liberal participants expressed favorable attitudes (indeed near ceiling for those identifying as
“very liberal” – 6.38 mean on the 7-point scale). More conservative participants were less
positive, although only the “very conservative” subset was below the midpoint on the scale (see
Table 1).
Relation between moral foundations and needle exchange attitude
In order to assess the association between moral foundations and needle exchange
attitude, we first assessed bivariate relationships between the MFQ and NEA using Pearson
correlation coefficients (see right columns of Table 1). Less positive attitudes towards needle
exchange was strongly associated with both Authority (r(5369) = -.45, p<.001) and Purity
(r(5369) = -.43, p<.001) concerns and more weakly associated with Loyalty concerns (r(5369) =
-.14, p<.001). More positive attitudes towards needle exchange were associated with concerns
about Fairness (r(5369) = .25, p<.001) and Care (r(5369) = .23, p<.001)
Next we carried out a linear regression analysis predicting NEP attitudes from the five
moral foundations. When interpreting individual Beta coefficients, it is important to consider that
the Moral Foundations are not fully orthogonal (Graham et al., 2011) and shared variance drives
down individual predictor beta values (though not the total variance explained in the model).
Together, the MFQ foundations explained 30.5% of variance in participants’ NEA scores. Less
favorable views of needle exchange were predicted most strongly by greater concerns about
Purity (std b =-.33; 95% CI [-.36, -.30], p < .001) and next strongly, by greater concern about
Authority (std b = -.21; 95% CI [-.25, -.18], p < .001). More favorable views of needle exchange
were predicted by greater concern about Care (std. b = .17; 95% CI [.14, .19], p < .001) and
12
Fairness (std b =.14; 95% CI [.11, .17], p < .001). The fifth foundation, Loyalty, was only
marginally associated with favorable attitudes towards needle exchange (std b = .03; 95% CI
[.00, .06]; p = .03).
Next we repeated the regression, this time after removing variance in NEA explained by
participant characteristics (political identification, education, religion, age, and sex, with all
predictors except age treated as categorical). This ensured variance shared between MFQ and
other included characteristics could not contribute to the statistical association between MFQ and
NEA. As shown in Figure 1, residuals from this model were predicted only by the Care and
Purity foundation, with greater concern over Care predicting more favorable needle exchange
attitudes (std b = .09 ; 95% CI [.06, .13]; p < .001) and greater concern over purity predicting
less favorable needle exchange attitudes (std b = -.18; 95% CI [-.22, -.15]; p < .001).
Next, because political identification was so strongly associated with NEA, we ran a
separate regression on the above residuals, this time only including participants who identified as
“Don’t know/Not political” (n = 194). We reasoned that this was informative because political
affiliations are strongly associated with moral foundations, and may directly mediate a relation
13
between moral foundations and needle exchange attitudes. While we attempted to account for
this through removing variance in NEA associated with political affiliation (and other
characteristics), this statistical adjustment is imperfect. Importantly, among participants who
self-identified as non-political, the effect size of Purity as a predictor of more negative NEAs
was of similar magnitude (std b = -.42; 95% CI [-.60, -.24] p < .001) to what was observed in the
full sample with covariates. No other foundation was associated with NEA in this small subset
(p’s>.2).
In order to explore the degree to which the findings might be specific to the US (where
just over two thirds of the sample resided) we split the sample into those that reported living in
the US (n = 3596) vs. those that reported living somewhere outside the US (n = 1711).
Participants not reporting country of residence (n = 62) were not included in either group. We
repeated the analysis predicting NEA after removing variance linearly associated with the other
regressors in the full model. Within the US sample, again, only Care and Purity predicted NEA,
with greater concern over Care predicting more favorable NEA scores (std b = .12; 95% CI [.07,
.16] p < .001) and concern over Purity associated with less favorable NEA scores (std b = -.19,
CI [-.24, -.15] p < .001). In the non-US sample, only Purity concern was associated with NEA
std b = -.15, CI [-.22, -.09] p < .001).
Finally, we were interested in whether political identification might change the
relationship between MFQ and needle exchange attitudes. Given the strong connection between
political identification and NEA demonstrated above, it could be the case that for some political
ideologies, a particular position on needle exchange is sufficiently mandated by the ideology that
other factors become less relevant. To assess this we used mixed effects modeling. A series of
models were constructed in which the intercept and slope of the relationship between moral
14
foundations and NEP were allowed to vary by political identification. We then examined the fit
of the “base model,” and compared it to models that allowed additional parameters for any or all
of the foundations. Specifically, we compare the base model to multilevel regressions with
random intercept and slope by political identification, using Bayesian Information Criterion,
where lower BIC indicates better model fit (Schwarz, 1978; Vandekerckhove, Matzke, &
Wagenmakers, 2015). Uniformly, we found that the models that provided the best fit allowed for
a random intercept by political identification, with a fixed slope for the NEP regressors. Thus
there was clear statistical evidence that political affiliations was associated with differences in
NEA (evidenced by the superiority of the models with random intercept) but not statistical
evidence that the relationship between moral foundations and NEA differed for different political
identifications (see Table 3 and appendices). In other words, in the best fitting model, a single
slope related moral foundation scores to NEP attitudes, regardless of political identification.
Conclusion:
The results of our study allow several conclusions. First, our NEA scale appears to
function as an internally reliable (a = .87) single factor scale. Second, positive NEA is strongly
related to liberal political identification and low religious identification. Third, and most

Model predicting NEP attitudes df BIC
Political identification only 3 16046
All Moral foundations only 7 15971
All Moral foundations + random intercept by
political identification
8 15447
All Moral foundations + random intercept +
random slope by political identification
23 15540

Table 3: Comparison of model fits for the prediction value of moral foundations and political
identification on needle exchange attitudes. Results demonstrate that the best models are those
that include the moral foundations with the intercept for political identification varying
randomly, and the model that the Purity and Care foundations with the intercept for political
identification varying randomly. See Appendix for model estimates

15
interestingly, individual differences in NEA are related to individual differences in level of
concern in the moral foundation of Care, and most consistently, to the moral foundation of Purity
concern. Those individuals who expressed greater concern for Care tended to have more positive
attitudes towards needle exchange programs, and those expressing greater Purity concern had
more negative attitudes. While other moral domains had some association with NEA in the
model without other predictors, only Care and Purity remained predictive when participant
demographic characteristics and political affiliation were included. And Purity alone was also a
significant predictor of needle exchange attitude among the subset of participants who resided
outside the US, and among the subset of participants that had no political affiliation. Multi-level
modeling did not provide evidence that relationships between NEA and MFQ differed as a
function of political identification.
Care and Purity Concerns in Needle Exchange
The associations between NEP attitudes and both Care and Purity concerns are perhaps
unsurprising. Needle exchange is a harm-reduction program, and it thus makes sense that it is
more attractive to those who view Care as a more dominant moral consideration. And while
needle exchange programs are directed at reducing the introduction of impurities (disease) into
the body, they entail association with impurity. The clientele, primarily homeless, are often
literally unclean, and there is a perceived high prevalence of engagement in morally unsavory
behaviors (related to obtaining drugs in the absence of regular income). In addition, the act of
injecting heroin into the body may itself be viewed as an act of body pollution (consider the
common phrase of “getting clean” used to indicate cessation of drug use). And the “exchange” in
“needle exchange” means that the programs will be involved in some way with the “dirty
needles” brought by clients.
16
The association between cleanliness and morality is clear in many religious traditions
(Shweder, Much, Mahapatra, & Park, 1997) as evident in common purification through cleansing
rituals (Lee, Tang, Wan, Mai, & Liu, 2015). A striking characteristic of the Purity domain is the
phenomenon of moral contamination –pollution of an individual through interaction with
impurity. Thus, for example, Judiasm, Islam and Hinduism all have rules that limit the contact
others can have with women during menstruation. In Hinduism, physical contact with the lowest
cast “Dailts” and any higher caste individual is thought to defile the latter (hence the designation
of the former as “untouchable”). In modern Westerners, contamination intuitions can be evoked
by hypothetical scenarios of contact with moral pollution such as reuse of a knife that had been a
murder weapon (Rozin, Markwith, & McCauley, 1994). The appeal of the aforementioned 2016
compromise allowing federal money to support needle exchanges but not be used for actual
purchase of needles can be understood in relation to contamination. From a consequentialist
point of view, the prohibition against using federal money for needle purchase is pointless.
Money is fungible, so it makes no consequential difference if an exchange uses federal dollars to
relieve the cost of staff or space rather than putting it in the needle purchase column of the
expense ledger. But the restriction may reduce the conceived contamination by putting
psychological separation between the taxpayer and the purity violation of injection.
If official organizations like NIH, CDC, and WHO are correct in their assessment of
needle exchange programs, then it is not an exaggeration to say that attitudes about the programs
are a matter of life or death. While our sample held, on-average, favorable attitudes about the
program, this is at least in part a consequence of our oversampling of politically liberal
individuals with low religious affiliation (indeed, NEA questionnaire responses were well below
the scale midpoint for those in our sample identifying as ‘very conservative’). Attitudes impact
17
the likelihood that needle exchange is made available. For example, California (a politically
liberal leaning state) presently has approximately 25 needle exchange programs. Texas (a
somewhat politically conservative leaning state) has none.
Moral Foundation Theory might offer a path forward. First, it provides a framework for
understanding moral attitudes and beliefs. People are disposed towards distinct categories of
moral intuitions. For someone with significant moral Purity concerns, providing needles to IV
heroin users might feel wrong. Heated rhetoric that ignores this may lead to entrenching
positions. Indeed even among those who, when asked, express support for needle exchange
programs, the force of the Purity violation intuitions may be impactful. For example, it may
make most people avoid thinking about the issue, and thus not actively engage in pushing back
against local and/or federal restrictions.
Second, Moral Foundations Theory may hold clues regarding the best way to create and
develop interventions directed at shaping public opinion. If the association between Purity
concern and NEA is at least partly driven by the former causally impacting the latter, then
messaging directed at minimizing purity violation imagery may be a promising approach. From
the standpoint of ameliorating purity concerns, messaging might 1) include minimal emphasis on
actual injection, 2) emphasize imagery and language that is high in positive purity content (e.g.,
clean, well-lit images with bright colors). Of course, what does and does not increase support for
needle exchange is ultimately an empirical question.
Limitations
Three limitations should be kept in mind. First, we used a convenience sample that was
certainly not representative of the World or US population. The sample was highly (almost
exclusively) Western. It was also relatively liberal, educated, male, secular and young.
18
Moreover, the sample characteristics include whatever attributes are idiosyncratic to a pool of
participants that navigate to a website about moral psychology. Related, it is possible that
specific awareness of Moral Foundations Theory, including awareness of its most well-known
finding that conservatives show more concern than liberals for binding foundations (Purity,
Authority and Loyalty), could impact study results. It is worth noting that the observed
association between Purity concern and negative needle exchange attitude was present even
when the sample was restricted to those identifying as non-political (as well as when analysis
stratified on US vs. non-US residency). It thus seems unlikely that the Purity-NEA association
was solely driven by awareness of the association between ideology and morality. However,
certainly our sample should not be taken as informative regarding the distribution of needle
exchange attitudes in the US, and the generalizability of observed associations to other
participant populations should not be assumed.
A second important limitation is the correlational nature of the data. Our discussion
implicitly suggests a causal hypothesis: that Purity concerns influence attitudes towards needle
exchange. Indeed, this hypothesis is what motivates our interest in these data. And yet, because
these data are correlational, conclusions are necessarily provisional. It is entirely possible that the
associations observed between moral foundations and attitudes are in no part causal. However, it
is a mistake to treat correlational data on this topic as categorically inferior to experimental data.
Moral concerns are impacted by experience and potentially interact with an open set of other
aspects of the person. Any manipulation directed at bringing a moral foundation concern under
experimental control (such as has been done in Mooijman et al., 2017) utilizes a specific model
that stands in for the impact of real-world variation in moral concern. The elevated moral
concern for a particular foundation that accompanies, for example, reading an evocative passage,
19
or sitting in an unclean environment, may have a different impact on judgments and behavior
than does real world elevation of concern related to the same foundation. While we believe
experimental work on the topic would add a great deal, in the absence of consistent correlational
data, its conclusions would also be provisional since they would depend on the generalizability
of the experimental model. Which is to say, the information gained by correlational data on this
topic is better thought of as complimentary to, rather than inferior to, the information gained by
experimental data (see Roher, 2018).
And finally, our study does not separate participant attitudes towards needle exchange
programs and their attitudes towards injection drugs users more generally. Follow up work
exploring the attitudes towards needle exchange programs and towards injection drug users could
help to distinguish the two.
Moral Foundations Theory provides a framework for characterizing divergent moral
attitudes towards needle exchange. If the associations observed here reflect (at least in part) a
causal influence of Moral Foundation concerns on needle exchange attitudes, then the framework
could also inform strategies directed at influencing attitudes more effectively.
20
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Abstract (if available)

Abstract Introduction: Needle exchange services reduce spread of disease. However, these services lack public support, in part because of moral misgivings. Research suggests that moral attitudes are grounded in at least five “foundations”: 1) Care, 2) Fairness, 3) Loyalty, 4) Authority, and 5) Purity. Understanding the moral basis of needle exchange attitudes could inform public health messaging. ❧ Method: Participants (n = 5369) completed a questionnaire on needle exchange attitudes (NEA) and also completed the Moral Foundations Questionnaire (MFQ). ❧ Results: The NEA had high internal reliability. NEA was most strongly predicted (in the negative direction) by individual level of Purity concerns followed by (in the positive direction) Care concerns. ❧ Conclusion: Moral Foundations Theory provides a framework for understanding moral attitudes towards needle exchange. Moral misgivings about needle exchange are associated with Purity concerns. If this association is causal, it may offer insight into how to build wider support for needle exchange programs.

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Creator Christie, Nina Caitlin (author)

Core Title The moral foundations of needle exchange attitudes

School College of Letters, Arts and Sciences

Degree Master of Arts

Degree Program Psychology

Publication Date 12/06/2019

Defense Date 12/06/2019

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag harm reduction,moral foundations,needle exchange,OAI-PMH Harvest,policy,syringe exchange

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Monterosso, John R. (committee chair), Bechara, Antoine (committee member), Lai, Hok Chio (Mark) (committee member)

Creator Email ncchrist@usc.edu,ninacchristie@gmail.com

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