Should People Be Paid to Get a COVID-19 Vaccine?

Marcia Frellick

January 12, 2021

Proposals to pay people to receive a COVID-19 vaccine to help the community reach herd immunity are morally flawed and unnecessary, say authors of a recent viewpoint in JAMA Network Open, and should be considered only as a last resort.

People have a moral obligation to get vaccinated to support their own health, help protect society, and quell the pandemic, argue Emily A. Largent, JD, PhD, RN, with the Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine in Philadelphia, and colleagues, in the viewpoint.

Being vaccinated to get a cash reward, they say, is an affront to that moral code.

Aiming for Herd Immunity via Cash Payments

In August, Robert Litan, PhD, a fellow in economic studies at the nonprofit Brookings Institution, wrote an editorial suggesting that Congress pay people $1000 for completing vaccinations, perhaps $200 up front and $800 when herd immunity is reached.

Although the payments would cost about $275 billion to cover 80% of the US population, Litan says it would be far less than the costs to the economy and society of not reaching herd immunity and continuing to isolate.

He argues that financial incentives are needed because of vaccine hesitancy, as evidenced by an August poll in which 35% of respondents said they wouldn't take a COVID-19 vaccine. A Pew Research Center survey in late November suggests acceptance is growing as 60% of respondents said they would get the vaccine, up from 51% polled in September.

However, Anthony Fauci, MD, the nation's leading infectious disease expert, told The New York Times in late December that vaccination rates of 70% to 90% may be necessary to protect the public.

Litan isn't alone in advocating for payments. John Delaney, a former congressman from Maryland and a 2020 Democratic presidential candidate, suggested in a November editorial in The Washington Post that the United States should pay adults $1500 to complete vaccinations.

"Cash payments would function as a double-stimulus," he said, providing economic relief and accelerating reopening of the economy.

Meanwhile, Houston Methodist Hospital has already started offering $500 to employees as a bonus for their hard work in the pandemic and for taking both doses of a COVID-19 vaccine.

Authors Say it's a Moral Obligation

In addition to the moral responsibility argument, Largent and colleagues write in the viewpoint that paying people to take the vaccine will be increasingly unnecessary. "It is likely that a majority of the population will be eager to get vaccinated as soon as possible in view of the extremely high and increasing number of SARS-CoV-2 infections and COVID-19–related hospitalizations and deaths."

Last week, COVID-19 death tolls began to surpass 4000 a day in the United States.

The authors also note that paying people to take the vaccine may signal to some that vaccination is riskier to their health than the government acknowledges if it thinks it needs to pay people to comply. They also say some groups, particularly those disadvantaged by the pandemic, may feel coerced to comply.

"Offering payment as an incentive for COVID-19 vaccination may be seen as unfairly taking advantage of those US residents who have lost jobs, experienced food and housing insecurity, or slipped into poverty during the pandemic," Largent and colleagues write.

Parallels With Insurers Paying People to Be Healthy

Nancy Jecker, PhD, professor of bioethics & humanities at the University of Washington School of Medicine in Seattle, said any talk of paying people to take the vaccine and protect society must be prefaced with the fact that the science hasn't yet proven whether vaccinating people will stop them from transmitting the virus.

She said paying people to vaccinate has parallels with insurance companies paying people to lose weight or stop smoking. She opposes those practices just as she opposes paying people to take the COVID-19 vaccine.

"I think a more compassionate response to someone with eating disorders or a nicotine addiction would be payment or other incentives to participate in evidence-based programs to help them lose weight or stop smoking," she said.

Similarly, "I wouldn't be opposed to paying people to listen to evidence-based education to learn about the risk and benefits of vaccines," she said.

Direct incentives have different effects on people depending on socioeconomic status, she said. In the case of Houston Methodist Hospital's payments to employees, she noted, the incentive might be an undue inducement for housekeeping staff while it wouldn't put pressure on an anesthesiologist.

A better alternative with perhaps longer-lasting effects might be a public health campaign encouraging uptake of the vaccine, she said, or restrictions on activities such as eating in a restaurant without proof of vaccination.

She said she doesn't buy into the idea that people won't get vaccinated without payment, and some of the initial hesitancy may really be people not wanting to be the first to take it.

"It's not a given that people won't take it," she said. "I think we should reinforce the intrinsic benefits to the person being vaccinated rather than distract them with money."

Nancy Kass, ScD, a professor of bioethics and public health at the Johns Hopkins Berman Institute of Bioethics in Baltimore, Maryland, told Medscape Medical News that she agrees with the authors that getting the vaccine is a moral responsibility and that paying people to vaccinate should be a last resort.

"We want people to want to get it," she said.

She notes that this is the time, before the vaccine is widely available, to better evaluate why people are still hesitant. The next couple of months also offer a chance for those who are hesitant to see millions more getting safely vaccinated and the numbers of infections and deaths declining.

"The more there are ordinary people [getting the vaccine] and peer influencers, whether it's Kim Kardashian or Tony Fauci or Oprah Winfrey, the more, I really think, the numbers of people who are hesitant will go down," she said.

Changing Societal Norms a Better Bet

There are better options, she said, including cultural restrictions that will incentivize people to get the vaccine.

When the vaccines move from emergency use authorization status to full authorization for all, she notes, schools and colleges may begin to mandate the vaccine for enrollment; couples getting married may require that in-person guests be vaccinated; workplaces may make vaccination a condition of employment; and airlines may require it for flights.

Those are better alternatives because they "express to the public that the people in charge think that it's time for this," she said. "There's a message we send when we say you've got to have a measles vaccine to come to school."

Also, Kass said, if you start paying people for COVID-19 vaccines, that could set an expensive and dangerous precedent for other essential vaccines and could threaten their uptake.

She says if people were paid to get the COVID-19 vaccine this spring, in the fall they may say, "How much are you going to pay me to go get my flu shot?"

The authors, Kass, and Jecker have reported no relevant financial relationships.

JAMA Intern Med. Published online January 6, 2021. Full text

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune, Science News, and Nurse.com and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick

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