Pay People to Get Vaccinated

Here’s a likely scenario for the Covid-19 vaccine rollout in the United States. The Federal Drug Administration will give emergency approval for at least one of the vaccines currently in development. As I write this in November 2020, the timeline of availability is unclear, but, especially at first, demand will outpace supply. Many more people want the vaccine than the number of vaccines that will be available early on. 

However, polls show that Covid-19 vaccine hesitancy is high. According to Pew, in May 2020, 72 percent of people polled said they would definitely or probably get the vaccine. By September, that number had dropped to 51 percent. A newer Gallup poll is more encouraging, finding that 58 percent of Americans would get a vaccine, up from a low of 50 percent in September. How this actually translates to vaccine rates is unclear. As we’ve learned, polls can be mistaken, and we don’t know the effect Biden’s win will have on vaccination support.

Still, for the sake of argument, let’s assume the polling is accurate. Even with Pfizer and Moderna reporting vaccine effectiveness of around 95 percent, vaccination rates will be too low to get herd immunity. Since no vaccine is zero-risk, and since these vaccines have more unknown risk (because they were developed so fast), we need a way to get people vaccinated. States could make vaccination mandatory, but there are lots of problems with this approach. For one, the high rates of hesitancy make it politically untenable. For another, it’s probably unethical, since the safety of the vaccines is less established.

In other words, in the world we’ll be dealing with, a vaccine is available, the FDA has decided that it’s safe enough for distribution, but there’s some risk involved in taking it, and there’s a collective interest in getting as many people vaccinated as possible.

Cash Is King

To accomplish the goal of high vaccination rates, policymakers should consider how to incentivize people to get vaccinated. Julian Savulescu has recently argued that people should be paid for the risk they’re taking on. Payment can also be used as an incentive. Other places are already using cash in this way: Hong Kong is paying people if they test positive for Covid-19 as a way of encouraging people to get tested.

Bioethicists and others in healthcare tend to get squeamish when financial compensation is proposed. There are four broad reasons people are against payment for services such as giving blood or organs, surrogacy, or participating in research: it’s coercive, represents undue influence, violates the dignity of those involved, or that payment negatively transforms the exchange. (See this episode from my podcast, Open Questions, where we explore some of these issues.)

For vaccine payment, coercion and undue influence are the most common objections, so let’s focus on those. Savulescu does an excellent job addressing these points, so see his article for details. Here’s a sketch. Some people worry that money is coercive, since it might get people to take part in something they otherwise wouldn’t have. The case against paying people for research participation in that such participation ought to be ‘fully voluntary’, which it won’t be (the argument goes) if payment occurs.

The problem with this argument is that it conflates ‘incentivization’ with ‘coercion’, yet one can occur without the other. Of course, people are incentivized whenever they get paid, but there’s no reason to think that, say, the people running the vaccine development have been coerced just because they receive compensation for their work. Indeed, the greater risk is that people won’t be compensated enough. In other cases of dangerous work, people appropriately get paid more.

A related concern is not about payment per se, but about the amount. According to The Belmont Report, an important research ethics document, undue influence occurs “through an offer of excessive, unwanted, inappropriate or improper reward or other overture in order to obtain compliance.” Some of these terms are difficult to define, but the general concern is that the money will prevent people from making authentic choices in line with their values, since they’ll be so focused on the money that they won’t rationally assess the risks involved. 

Importantly, many people involved in Institutional Review Boards set this threshold at zero. One survey of IRB members and researchers found that “The majority (61 percent) of respondents reported feeling somewhat, moderately, or very concerned that payment of any amount might influence a participant’s decisions or behaviors regarding research participation.” 

There are risks with monetary compensation, but those study participants are wrong to be concerned that any amount of money could be unethical. Applied to the vaccine, if governments do decide to pay people to get vaccinated, it seems unlikely that the amount offered will constitute undue influence. Of course, some people who weren’t going to get the vaccine (or were going to wait) will decide to get it sooner, but that’s the point. Including monetary compensation in one’s deliberations can be both rational and in line with one’s values.

Whether or not money is involved, clear communication about the risks, both known and unknown, will be important. The best way to prevent payment from playing the wrong role is to be open with the public. People can then decide for themselves if vaccination is worth it.