By Nancy S. Jecker

A utilitarian thinks ethics is a lot like math.  We want to produce the greatest good.  If a disease will create a lot of harm and a vaccine will create a lot of good, we should do what it takes to get shots in arms. If it takes paying people, then pay, up to the point where benefits outweigh costs.  In the COVID-19 vaccine rollout, this logic seems to show payment is the way to go.

The problem with this approach is that ethics is not much like math. The ends do not always justify the means.  What if getting everyone vaccinated required false advertising? Obviously, considerations other than maximizing benefits factor in. We value honest relationships, treating people as equals, and respecting others’ reasons and choices.

We also value health equity. Payment has unequal effects on different segments of society, exerting more force and coercion on the most disadvantaged. Take the case of Houston Methodist Hospital in Texas, which has reportedly offered to pay employees $500 to be vaccinated against the SARS-Cov-2 virus.  Even if that is not undue inducement for say, an anesthesiologist it very well might be for a cafeteria worker or custodian. This is a time of dire economic distress, when many people have lost jobs or their family members have, and they are worried about paying rent.  The U.S. and other societies lack an adequate safety net to help the poor and unemployed; payment for vaccination is coercive in these countries in ways it might not be in others.

Good ethics also requires good facts. The utilitarian assumes that some people won’t get vaccinated unless they are paid. But where’s the evidence? Doubts about the COVID-19 vaccine may in fact diminish over time, as more people take the vaccine without untoward effects, as public health campaigns kick in, and as people see others they know becoming vaccinated. Some people who do not want to be the first in line, may get vaccinated soon, as more data become available about vaccine safety.

Paying people could in fact backfire. It could prompt suspicion, leading people to perceive vaccine risk is higher than they are being told. Even if it worked short-term, would it work in the long-term? What happens if the public starts to expect or demand payment for other vaccines, feeling entitled to have vaccine risk routinely offset? What happens after the COVID-19 pandemic subsides, and the next emerging infectious disease comes along?  What if it turns out vaccines against the SARS-CoV-2 virus must be given annually? Would paying people set up a costly expectation for annual payments? Payments to get shots in arms is short-sighted and unsustainable.

What is the best way to get shots in arms?  There are plenty of less coercive methods, like public health campaigns that tout benefits, such as staying healthy, travelling safely, gathering with friends and family. Other measures, such as making benefits, like seeing a movie or eating in a restaurant, contingent on vaccination, are less coercive options than payment and could be easily implemented using a scannable code on mobile phones that shows proof of vaccination.  Less intrusive alternatives can also take the form of encouraging private industry contributions, such as offsetting costs by offering free transportation to vaccine sites and giving employees paid time off to get a shot. Lastly, less intrusive alternatives can take the form of curbing vaccine misinformation on social media and e-commerce by means of tools like bias meters and source bias warnings, e.g., ‘The author is a known anti-vaxxer.” In the U.S., the American Medical Association has called on leading social media and e-commerce companies to shoulder responsibility for reducing online dissemination of vaccine misinformation. Psychologists tell us that one of the best nudges for vaccination are old fashioned reminders.

Ultimately, the best way to take on vaccine refusal is teaching providers how to communicate with adult patients about vaccine benefits and risks. Evidence shows that the most consistently reported factor in vaccine decision-making is conversations people have with providers.  Even when people do not trust their government or the for-profit pharmaceutical companies that develop and manufacture vaccines, they are apt to trust healthcare providers.  For members of black and brown communities, having a provider with the same racial and ethnic background they can talk to helps diminish vaccine reluctance.

We can pay people to do a lot of things.  But should we? In the case of getting them to take a vaccine, the answer is resounding ‘No!’

Paper title: What Money Can’t Buy: An Argument Against Paying People to Get Vaccinated

Author: Nancy S. Jecker

Affiliations: University of Washington School of Medicine, Department of Bioethics and Humanities

Competing interests: None

Social media accounts of post author(s): Twitter: profjecker