Article Text

What money can’t buy: an argument against paying people to get vaccinated
1. Nancy S Jecker
1. Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, Washington, USA
1. Correspondence to Dr Nancy S Jecker, Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA 98195, USA; nsjecker{at}uw.edu

## Abstract

This paper considers the proposal to pay people to get vaccinated against the SARS-CoV-2 virus. The first section introduces arguments against the proposal, including less intrusive alternatives, unequal effects on populations and economic conditions that render payment more difficult to refuse. The second section considers arguments favouring payment, including arguments appealing to health equity, consistency, being worth the cost, respect for autonomy, good citizenship, the ends justifying the means and the threat of mutant strains. The third section spotlights long-term and short-term best practices that can build trust and reduce ‘vaccine hesitancy’ better than payment. The paper concludes that people who, for a variety of reasons, are reluctant to vaccinate should be treated like adults, not children. Despite the urgency of getting shots into arms, we should set our sights on the long-term goals of strong relationships and healthy communities.

• COVID-19
• autonomy
• ethics
• paternalism
• public health ethics

## Data availability statement

There are no data used for this work.

## Introduction

Should we pay people to get vaccinated against the SARS-CoV-2 virus? In August 2020, before the first vaccines against the novel coronavirus were even available, Litan, a Brookings Institution Fellow, championed the approach. Comparing paying adults to get vaccinated to handing candy out to children after a shot, Litan called it a harmless enticement to ‘take the sting and fear out of the shot’.1 Litan expected that $1000 per person would do the trick: ‘At that level, a family of four would get$4000…—a lot of money to a lot of families in these difficult times, and thus enough to assure that the country crosses the 80 percent vaccination threshold’ required for herd immunity.1 He calculated the United States (US) price tag at roughly $275 billion. Months later, when promising vaccines were on the horizon, a version of the proposal was endorsed in opinion pieces appearing in the Washington Post2 and New York Times,3 and by bioethicists, such as Savulescu, who favoured payment as a last resort if voluntary vaccination measures fell short.4 The argument on the other side has not yet received a fair hearing. This paper fills the gap, arguing unequivocally against payment. The first section introduces a set of initial reasons why payment is ill advised, while the second section shows where the fault lies in arguments on the other side. The third section points to best practices for addressing vaccine refusal now and in the future. Throughout, I focus on US society, although many of the arguments considered could be adapted and applied outside the US. ### Arguments against payment There are three compelling reasons to reject paying adults to get vaccinated against the SARS-CoV-2 virus. #### Better alternatives First, there are better, less intrusive alternatives. These include, for starters, public health campaigns that tout the intrinsic benefits of vaccination, such as staying healthy, travelling safely and gathering with friends and family. These benefits are the natural consequences of vaccines that will become apparent and encourage people to get inoculated. Other strategies that are less intrusive than payment include making certain benefits contingent on proof of vaccination, while allowing exceptions for people with medical, religious or disability objections. For example, once vaccination is widely available, travelling on planes, attending school in person and eating in a restaurant could require proof of vaccination, perhaps using an app with a scannable QR code. Such a strategy has a long history, dating back to smallpox outbreaks in the 1880s that prompted schools to require students to show vaccine credentials.5 During the 1960s, the WHO introduced a widely used yellow card to document vaccination for international travellers. Today, an electronic app (CommonPass) developed by a non-profit organisation (The Commons Project Foundation) is already being used by major airlines to document negative test results, with plans underway to use the app to verify vaccination. Less intrusive alternatives can also take the form of encouraging private industry contributions, such as offsetting costs by offering free transportation to sites, and giving employees paid time off to get a shot.6 Lastly, less intrusive alternatives can take the form of curbing the promotion of misinformation by social media and e-commerce through short-term strategies, such as bias metres signalling misinformation bias, or source bias warnings, for example, ‘The author is a known anti-vaxxer.’7 Such efforts are already underway. Facebook,8 for example, has instituted policies banning vaccine misinformation and the American Medical Association has called on six leading social media and e-commerce companies to ‘help shoulder the burden of identifying and eliminating misinformation online before it is widely disseminated’.9 Yet someone could say these alternatives to payment are intrusive too. Kofler and Baylis, for example, oppose requiring vaccination to access benefits, warning against a ‘dystopian future’ on the ground that ‘any documentation that limits individual freedoms on the basis of biology risks becoming a platform for restricting human rights’.10 Yet this slippery slope objection is not backed by evidence. In the US, for example, laws in many states already require proof of various vaccinations (eg, against hepatitis B, measles, mumps, rubella, pertussis, pneumococcal disease and varicella) as a condition for working in healthcare facilities, attending public and private schools and going to day care (with allowance for people with medical, religious or disability objections). Travellers entering the US from certain regions likewise must document certain vaccinations. These settings have not emerged as ‘dystopian nightmares’, but as safe zones, assuring larger liberties. Admittedly, requiring proof of vaccination is to a certain extent intrusive, like requiring a licence to drive a car is, or a seat belt to travel in one. In these, and many other instances, we make trade-offs. #### Unequal effects Second, payment for getting vaccinated would have unequal effects on different segments of society, exerting more force and coercion on members of lower socioeconomic groups. Take the case of Houston Methodist Hospital in Texas, which has reportedly offered to pay their employees$500 to take the COVID-19 vaccine.11 Even if a \$500 payment would not constitute an undue inducement for a highly paid physician, such as an anaesthesiologist, it might well represent that for a cafeteria worker or custodian who earns considerably less.

Against this reasoning, Savulescu acknowledges that ‘those who are poorer may be more inclined to take the money and the risk’, yet notes, ‘this applies to all risky or unpleasant jobs in a market economy.’4 Savulescu is right: people who are poor have less choice in many areas of life. That is precisely why we should not make matters worse. The status quo in the USA is an unfair economic environment, marked by structural racism and inequality in many areas of life. Surely this cannot serve as the ethical justification for a vaccine payment scheme. Vaccine payment modelled on low-wage jobs that entice the poorest Americans would only mirror and reinforce inequity.

Yet it could be argued that precisely because payment would boost vaccination rates among disadvantaged groups, the strategy recommends itself. According to this line of thinking, it helps, rather than harms, vulnerable people to protect them against a deadly disease. Yet, in reply, the empirical claim that payment will protect the vulnerable might not be born out. Rather than increasing vaccination rates, payment could backfire. For example, payment may prompt suspicion, leading people to perceive payment as a sign that vaccine risk is higher than they are being told. A better way to build trust is to treat people with respect, sitting down and listening to those who are opposed to or unsure about vaccines.

#### Economic distress

A third argument against paying people to get vaccinated holds that the pandemic has produced unprecedented rates of unemployment and economic distress for individuals and families. Therefore, paying people to get vaccinated is more manipulative now than it otherwise would be. With US unemployment at an all-time high, far fewer people perceive themselves as free to refuse payment—they need money to pay bills and purchase food. For those who have lost jobs or have family members that have, an offer of payment for vaccination might be extraordinarily difficult to turn down. Especially in societies, such as the US, which lack an adequate safety net to help people who are poor and unemployed, payment is coercive.

### Arguments for payment

#### Health equity

Yet proponents of payment might press the point that vaccines would in fact help disadvantaged groups by boosting vaccine rates. For example, Black Americans, who are disproportionately adversely affected by the novel coronavirus, are more reluctant than the population at large to get vaccinated against the SARS-CoV-2 virus. A June 2020 PEW Research Center poll found that fewer than half of Black Americans planned to get vaccinated against the novel coronavirus, compared with 60% of Americans overall.12 A December 2020 Kaiser Family Foundation report found that 27% of Americans remained vaccine hesitant, compared with 35% of Black adults.13 In February 2021, more than 90 days into a US vaccination drive, an Associated Press-NORC poll reported that Black Americans remained among the group most likely to express vaccine reluctance.14 If a payment plan were implemented, this would potentially help Black Americans (and perhaps other minority groups) overcome hesitancy, and ultimately reduce the disproportionate toll the virus would otherwise take. In other parts of the world, similar patterns of vaccine caution are evident among minority populations and a parallel health equity argument can be made.15

In reply, a somewhat fairer alternative to payment is a traditional across-the-board mandate, which could be applied to healthcare workers in hospitals, people who ride public transportation or those attending public schools and universities, while allowing accommodations for medical, religious or disability reasons.16 Such an approach takes less advantage of people’s economic situation. It leaves people freer to choose whether to avail themselves of benefits or opt out of vaccination, while still allowing people with recognised exceptions to enjoy the same benefits as vaccinated individuals. Admittedly, this is not a perfect solution either. It still plays against the poor and marginalised, who are more likely than their wealthier counterparts to rely on public transport, public schools and public universities. Should payment for vaccines be given alongside across-the-board mandates as a way to expand choice? In reply, payment would do little to provide people who rely on public services viable alternatives to mandates. It will not offset tuition at private schools and universities or cover the cost of a private vehicle; it will not make changing jobs (to avoid a mandate) easier.

#### Consistency

Still, someone might point to the fact that we already permit insurance companies to pay people to lose weight and stop smoking. How does paying people to get vaccinated differ? To be consistent, shouldn’t we allow insurers to pay subscribers to get vaccines, which would reduce the cost of insuring them? In both instances, the goal is to enhance health; in the case of vaccination, the argument is even stronger, assuming vaccination enhances other people’s health too.

However, this argument assumes that paying people to lose weight or stop smoking is itself ethically acceptable. Yet, there are compelling reasons not to pay people for these triumphs, since doing so assumes that they are fully responsible—free to ‘just say no’. A better, more compassionate way to help someone break the cycle of disordered eating or nicotine addiction is payments (and other incentives) to participate in evidence-based programmes that will help them quit smoking or lose weight and thereby lead healthier lives.

#### Being worth the cost

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? Perhaps a proponent of payment would argue that the costs of an economic shutdown would be worse, as would the economic, not to mention human, toll of unvaccinated people filling up hospitals. However, this argument assumes that people won’t get vaccinated unless they are paid. But it is an empirical question whether that is the case. Doubts about the COVID-19 vaccine may in fact diminish over time, as more people take the vaccine without untoward effects, as moral leadership shifts, as public health campaigns kick in and as people see others they know becoming vaccinated. Some people do not want to be the first in line, and may plan to get vaccinated soon as more information about vaccine safety becomes available.

#### Autonomy

Would payment compromise autonomy? Some dismiss this concern, arguing that the top priority should be getting shots in arms, while reasoning that respect for autonomy can ‘work alongside a payment scheme’.4 Yet, this strategy is psychologically naive. Respect for autonomy cannot simply be added on, as an adjunct to payment. The message that payment sends is ‘regardless of what you think, we want to get this shot in your arm’, while the message that respecting autonomy sends is ‘what you think matters to the utmost; it alone will determine whether this shot goes in your arm’. In the former case, the relevant question is: ‘name your price’. In the latter case, it is: ‘what are your concerns?’

Credibly addressing people’s reasons for refusing vaccines begins with changing our language. ‘Vaccine hesitancy’ suggests a person is hesitant to do something they ought to do. Hesitancy is something a person should try to overcome. The language prejudges a choice and potentially stigmatises people holding outlier views. Notice that we do not refer to those who eagerly line up for jabs as ‘vaccine enthusiasts’, which would prejudge them as thoughtless and overly eager. A better way of referring to those who decide not to get vaccinated might be ‘watchful waiters’ when reluctance stems from not having made up one’s minds or deliberately choosing to delay. This term implies thoughtful refusal, gathering data and postponing deciding. ‘Vaccine deliberator’ is also a better label than ‘hesitant’, because it connotes deciding with care and caution; it is apropos when the group referred to has a range of reasons, perhaps unknown, for not being first in line. These terms invite conversation because they treat people as equals and suggest open-mindedness to others’ choices and reasons.

The next step is sitting down and talking, done in a way that treats people who refuse vaccines as equals and tries to understand their reasons. Admittedly, it is hard to stop and talk during a crisis. People feel impatient, even hostile, toward those who are not dutifully lining up to get jabbed. Yet, ethically, there can be no quick fix. Once we start down the path of listening, it becomes apparent that attitudes toward vaccines vary widely—ranging from complete refusal of all vaccines to selective acceptance of some. Some individuals get vaccinated while feeling unsure about doing so, while others purposively delay. Vaccine dissent varies among socioeconomic groups and based on level of education.17 As noted, it varies along racial and ethnic lines, with significantly greater vaccine caution reported among Black Americans than the population at large.18 Some people who are apprehensive about COVID-19 vaccines express concern that the rapid roll-out in the USA under ‘operation warp speed’ compromised science in ways that the public does not yet know. Others express concern based on media reports that US scientists involved in developing vaccines and/or the federal agencies that approved them were politically pressured by the federal government, potentially compromising the science vaccines were based on. Even if payment induces some among these vaccine careful people to change their behaviour and get vaccinated, it may not change their underlying beliefs or address their true concerns. This could have implications for future vaccination efforts. What happens if people need annual shots? 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? Payments to get shots in arms are short-sighted and unsustainable.

#### Good citizenship

Proponents of payment for vaccination might think that those who refuse to get vaccinated are free riders who shirk their duties as citizens. This argument is reminiscent of debates in England during the 19th century. Following passage of the Vaccination Act of 1898, parents (primarily working class women) were no longer fined or imprisoned for refusing to vaccinate their infants against smallpox and could instead apply to a magistrate for a certificate of conscientious objection. Proponents of vaccination ardently criticised those who exercised this legal right, claiming it was ‘part of the duty of good citizenship’ to be vaccinated and to protect the nation from disease.19 Conscientious objectors had a different idea of ‘good citizenship’. They held that good citizens respect the bodies of their neighbours and honour their right to exercise their conscience.

Today, defenders of paying people might make a parallel claim, holding that payment can help people do the right thing, cultivating concern for the community. Especially for low-risk populations, such as healthy young adults, proponents of payments might think an added incentive is needed to encourage them to assume risks they perceive as primarily helping others.4 According to this line of reasoning, in the long run, payment will inculcate good habits and help people be more moral.

In reply, rather than inculcating a sense of responsibility for neighbours, paying people might lead them to be less inclined to do the right thing if they are not paid. Character and a sense of civic duty are things money cannot buy. Kant’s insight could not be more apropos: the worth of an action lies in the reasons why a person acts, not the ends they achieve.20 Inducing people with money to act in a certain way does not make them more moral, it gives them reasons for action that have nothing to do with morality.

#### Ends justify means

A utilitarian would probably remain unconvinced. For them, moral questions are a lot like math. If a disease will create widespread suffering and vaccination can offset this by producing overwhelming benefits, we should vaccinate, using whatever means necessary to achieve herd immunity, provided we do not create more pain and misery in the process. Yet should we really do whatever it takes? Imagine we had the kind of vaccines we could sneak into water supplies, should we do that if it created more benefit than harm? While highly stylised, this example establishes a crucial point: considerations other than the public good matter. In a just society, we value honest relationships and we strive to be worthy of each other’s trust. We respect people’s autonomy and we regard others as moral equals.

#### The threat of mutant strains

Finally, proponents of payment may argue that rapidly spreading variants of the SARS-CoV-2 virus are emerging that could reduce immune responses triggered by vaccines or prior infections. As a result, time is running out. Under these emergency conditions, we are justified in granting trusted leaders whatever powers they need to reach herd immunity fast.

In reply, it is worth noting first, that proponents of payment are not trusted leaders, but the heads of for-profit private industries. Even if they would like to do right by their employees, they face a conflict of interest. Second, COVID-19 vaccinations received emergency authorisation and have not yet been subject to full scientific review. This weakens the argument for coercive tactics of any form, including payment. For precisely this reason, groups routinely subject to vaccine mandates, such as healthcare workers and members of the military, have not yet been mandated to take the COVID-19 vaccine. Third, we face a glaring gap in data: we do not even have evidence establishing that commonly used COVID-19 vaccines reduce or prevent infection and transmission. Given this, paying people is premature because it may do little to protect others. In fact, it could make matters worse if vaccinated individuals take off their masks and mingle as usual.

### Best practices

The best way to address vaccine refusers is not with checks in hand, but with a willingness to listen and try to understand. Only through better understanding the various reasons underlying lack of trust can we persuade people to get vaccinated. As the World Health Organization (WHO) instructs, ‘communities must be supported in seeing value in vaccines’ and they must be supported ‘in conveying their…needs and perspectives on how vaccine programs are delivered to key decision makers’.18 Trust in vaccines depends on confidence in vaccines and the system that produces them.21 Ultimately, an autonomous decision to be vaccinated is made because one sees the value of vaccines for oneself and one’s community, not because factors, such as money, lead one to go along.

#### Long term

In the long term, the most promising way to address vaccine refusal is teaching healthcare 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 the conversation people have with providers.17 Even when people do not trust their government or the for-profit pharmaceutical companies that develop and manufacture vaccines, they are apt to trust their providers. For members of Black and brown communities, having a provider with the same racial and ethnic background they can talk to can help address vaccine concerns.22

#### Short term

Yet, where does that leave us in the short term? During the COVID-19 pandemic, respect and trust can be established by partnering with communities to develop public health campaigns that speak effectively to diverse populations. For example, in the US, vaccine reluctance among Blacks is ‘a direct consequence of the medical system’s mistreatment of Black people’; the solution might include:

Oprah Winfrey could use her television network to bring to life Covid-19 survival stories and the reality of the disease’s long-term effects. Michelle and Barack Obama could be vaccinated on national television, as Vice President-elect Kamala Harris was…; LeBron James could tweet about the importance of getting the shot to his 49 million followers. Black social media influencers could post photos of their shots. The ‘Divine 9’ historically Black fraternities and sororities could host a national vaccine stroll encouraging immunizations. Pastors and hairdressers could use their social ties to rally their communities around vaccinations.22

Litan was wrong when he suggested payment was a good idea for adults since candy was for kids. That patronising stance sends precisely the wrong message to people who do not trust vaccines. It suggests that adults who are reluctant are child-like and must be coddled. Rather than treating poor and disenfranchised members of society, who are the most vaccine careful, like children, we should respect their freedom to choose and treat them with the respect all people are due.

## Data availability statement

There are no data used for this work.

## Footnotes

• Contributors NSJ is the sole author of this paper.

• Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

• Competing interests None declared.

• Provenance and peer review Not commissioned; externally peer reviewed.

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