By Nathan Hodson and Ray Jerram.

The coronavirus pandemic had enormous consequences for children. Around the world, children missed months or even years of school, losing out on learning, exercise and friendship. Although they generally had far lower morbidity and mortality from SARS-Cov-2, the loss of grandparents and parents affected many.

Children were also the last group to be offered the vaccine. This was due to both the prioritisation of older people and differences in regulatory approval for treatments for children. When eventually offered the vaccine, children’s uptake was lower than in many other groups.

This inertia posed a problem for society because children were viewed as potential vectors of disease. Healthy children risked transmitting the coronavirus to older family members, teachers, or children at high risk of complications due to chronic diseases. Public health action was required.

One solution employed across several US states was to implement a vaccine lottery. Vaccine lotteries had been implemented among adults during the early months of the vaccine effort and had been reasonably popular. Some teenagers had even been included in vaccine lotteries for adults. But by December 2021 some states decided to implement vaccine lotteries specific to children aged 5-11.

In West Virginia, Governor Justice announced “Do It For Babydog”, a vaccine lottery for 5-17 year olds which continued throughout 2021. The rules were simple: every West Virginian aged 5-17 who had received one vaccine was entered into a prize draw. The grand prize was $100,000 educational savings fund – i.e. a college scholarship. There were tens of other $10,000 educational savings funds on offer, as well as lifetime hunting and fishing licences, a school-based prize and a party with Governor Justice’s dog, “Babydog”.

Ethical Analysis

Using financial incentives to promote healthy behaviours can prompt a sceptical reaction: is it ethical?

Halpern, Madison and Volpp wrote Patients as Mercenaries? The Ethics of Using Financial Incentives in the War on Unhealthy Behaviors which described five key ethical concerns which are raised when financial incentives are used in healthcare and offered potential counterarguments. Although it is not an exhaustive review of all possible ethical issues, their paper describes several key domains worth considering. In what follows we will evaluate covid vaccine lotteries for children in the context of their ethical analysis.

The first objection is that financial incentives unduly infringe on autonomy. Halpern, Madison and Volpp contend that financial incentives merely counter the human drive for immediate gratification (or avoidance of short-term discomfort), rather than undermining autonomy in a problematic way. The tendency to immediate gratification is more pronounced in children, perhaps bolstering this justification. However, the financial benefits offered in vaccine lotteries are by no means immediate; they may not materialize for 10 years or more. These lotteries counter the tendency to overvalue short-term pain – a tendency which can erode autonomy –  not by providing a small immediate counterbalance to the small immediate pain, but a potentially large distant counterbalance.

The second objection is that financial incentives are unfair on the most vulnerable. The authors contend that this would be an objection against tobacco taxes which take money away from the poorest and most vulnerable, rather than against incentives which give money to many vulnerable people. Child covid vaccine lotteries also transfer money to people who otherwise would not have it, and this is not unfair. Moreover the need for heard immunity means that vaccination anywhere benefits people everywhere – especially the most vulnerable.

A third objection is that financial incentives crowd out intrinsic motivation or deemphasise the value of hard work. The authors say this is only a theoretical problem. But it should be considered seriously as it cannot be ruled out. Given that only a few scholarships were awarded, many people will continue to compete for merit scholarships (or to earn enough to buy fishing licences) so it is difficult to see the value of hard work being eroded by child vaccine lotteries. It is plausible that children will, in the future, decline the covid vaccine without a lottery to incentivise them, but the majority of children were already declining covid vaccination prior to the incentive so the impact of crowding out in this context can only be small. These objections are important but should be considered unlikely to materialise.

The fourth objection is that incentive programs require an interference with personal privacy. Patient data (showing that they have chosen the healthy option) must be passed to an external body in order to administer prizes. Halpern, Madison and Volpp propose that any financial incentive scheme should come with an opt-out for those who value privacy over their chance at a prize, yet this was not offered in the child vaccine lottery schemes. In the case of covid vaccination, data on individuals’ vaccine status was being collected regardless. Given each individual vaccination benefits the whole community, it is unclear that vaccination status is legitimately private. Many policy decisions (vaccine passports, for example) have been justified by the idea that non-vaccination should be permitted but has societal consequences justifying monitoring.

The final objection is that financial incentives are unfair on those who select healthy options, irrespective of the incentive. They point to never-smokers who miss out on incentives to quit despite making the healthy choice. Halpern, Madison and Volpp argue that people with healthy lifestyles already pay for the unhealthy lifestyles of others through health insurance or taxation. In fact, financial incentives for health choices could potentially save healthy people money by reducing the number of unhealthy choices made. However, in the context of child covid vaccine lotteries, every vaccinated person was eligible to win a prize, not only the those who had been delaying vaccination.

Other objections

Although none of Halpern, Madison and Volpp’s main ethical controversies about financial incentives are of particular concern in the context of child covid vaccine lotteries, the arrangement throws up some novel objections which should be considered: 1. Children who were ineligible for the vaccine were excluded from the lottery, for example those with allergies. 2. Child-only vaccine lotteries exclude children from the shared endeavour to overcome the pandemic by treating them as, in Halpern, Madison and Volpp’s words, “mercenaries”. 3. Vaccine lotteries exploit the irrational tendency to overrate one’s likelihood of winning, thereby potentially subverting dignity. 4. Parents concerned about the cost of college may exert inappropriate pressure on children who would otherwise not consent to the vaccine. Future research could assess whether these objections present barriers to future child vaccine lotteries during future pandemics.

Authors: Nathan Hodson and Ray Jerram

Affiliations: NH: University of Warwick; RJ: Kings College London

Competing interests: None declared

Social media accounts of post authors: @nathanhodson