Are COVID-19 Vaccination Incentives Ethical?

John Whyte, MD; Arthur L. Caplan, PhD

Disclosures

June 08, 2021

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JOHN WHYTE: Welcome, everyone. You're watching Coronavirus in Context. I'm Dr. John Whyte, the Chief Medical Officer at WebMD.

Everyone seems to be getting something free nowadays for getting the vaccine. Free doughnut, free beer, free college tuition. But is this ethical? Is there undue influence? Whenever I have an ethical question, I go to my expert ethicist, Dr. Art Caplan, Professor of Bioethics at NYU Langone Medical Center. Dr. Caplan, thanks for joining me.

ARTHUR CAPLAN: Hey, John. Thanks for having me.

JOHN WHYTE: Let's get right to it. I mean, we're offering -- the little things I can see. A doughnut, a beer. Apparently, on July 4th, we all might get a beer if we reach 70%. OK, I'm OK with that.

But what about when we're talking $500 cash incentive that some businesses have announced? Lotteries for free tuition at a state school. Where do you draw the line and say, you know what, some is fun and games, and some is undue inducements?

ARTHUR CAPLAN: Well, I'm not in principle opposed to inducements or prizes to encourage good behavior. I mean, I think it's better here in terms of trying to get somebody to get vaccinated than it might be to say, you know, we'll give you a free drink if you promise to spend $5,000 in our casino, which I think could lead to bad outcomes for individuals who might not be able to rein in their gambling. So it's in the service of public health. I like that.

But I think there are a couple of boundaries I would remark on. West Virginia started to offer guns as a reward for vaccination. These days, I don't think that's probably the best public health maneuver, given our problems with gun violence.

And there are other rewards that are coming along where people have said, doughnuts? We have an obesity problem, isn't that bad? But again, you don't have to take the doughnut. You don't have to eat the doughnut. And I don't think anybody's going to become obese by the free doughnut giveaway. That one doesn't bother me. I heard those criticisms. It's a minor reward.

I do think, though, there are people who are going to say, this isn't fair. I already got vaccinated. You're rewarding the people who didn't do the right thing. What about me? And there may be opportunities to let them enroll in that lottery or let them become available for a benefit. I wouldn't want to exclude people just because they'd already done the right thing and gotten themselves vaccinated. So that's a justice issue, and I think people who are offering these awards should take it into account.

It would be nice too if we had a reliable way to prove that we're vaccinated, but we keep fending that off. We have our little CDC cards and so on, but they're not chipped and they're not really trustworthy all the way. You can forge them.

The other main question, though, is the one you're pointing out. What if you can't say no? What if it's just like, this reward is so great. Then I'm going to find myself almost coerced into doing what they want. Well, normally I don't like that. I think it's not consistent with a real choice to give a reward that's so huge that a poor person is going to say, how can I not get vaccinated?

But in all honesty, if the behavior is getting vaccinated, I can live with it. I'll draw this moral line. If it's something that's definitely beneficial to you, your family, and your community, if it's minimal, minimal risk, even though it's a really super strong inducement, I'm going to tolerate it in the name of public health.

Where you and I might want to draw a line is, what about kids? Kids can't really make those choices. Their parents are making them for them. If you're offering the parents a gigantic restaurant meal or something, they're like, well, that's great and I'm not going to worry so much about what happens to my kid. That seems to me wrong. I don't think we should be having a super strong inducement system when kids are involved.

With adults, we do have state lotteries now. We do give gigantic prizes for no reason other than you can throw a dollar away every day and try and face enormous amounts of benefit.

JOHN WHYTE: I'm just only asking people to throw a dollar away. I'm not asking them to get a shot in their arm in that setting. So there is a difference, isn't there?

ARTHUR CAPLAN: There's a difference, but I'd say it's still good for you, good for your family, good for your community. You're going to come away with a lot more benefit than if you throw that dollar away on the state lottery every week. There, I think you're chasing odds that are ridiculously long.

JOHN WHYTE: Is there dollar value for something that crosses the line for you?

ARTHUR CAPLAN: Yeah, that's a great question.

JOHN WHYTE: Maybe $500 that a employer may offer, or even $1,000, some are suggesting. Does that cross the line based on dollar value?

ARTHUR CAPLAN: So it's a good question, and I think it's context. If you're offering someone an enormous sum of money relative to where they are to the -- and here's how I measure it. If you can't tell me what the risks are, if you can't tell me what the downside is, you're just there for the money, I start to get nervous.

If you can say, yeah, it's a shot, I might be tired for a day, I might have a sore arm, I could even get headaches or other adverse events from it, and I heard somewhere there's an enormously tiny risk that I might suffer, let's say, a heart inflammation problem, but I'm in, OK.

JOHN WHYTE: Even if you otherwise wouldn't have done it?

ARTHUR CAPLAN: Even if you otherwise wouldn't have done it.

JOHN WHYTE: Not just a fence-sitter, but maybe you were a no. Is it different if you were a fence-sitter, like you were leaning towards it but you weren't sure, versus you were no, and then the inducement just seemed a little bit too much?

ARTHUR CAPLAN: Well, it's funny. You put that very well. And I'm going to say, If you're a fence-sitter and an inducement tips you over, I find that more successful and more defensible than if I was sitting there saying, I've never been vaccinated, I hate vaccines, but you know, for free beers every day for a year, I'm in. I'd worry you're not really making a intelligent choice. You're not really listening to what the facts are.

But I don't think you're going to see the hardcore anti-vax people moved by any of these incentives. They are so strongly dug in. Boy, it's tough to get them.

I think these are all targeted at either the hesitant or those who are inconvenienced. To be honest, there are some people saying, I can't take a day off to go over and get this darn vaccine. My boss is going to come after me, or it's going to cost me money to take a taxi or an Uber or subway. But you know, maybe for a chance at that free meal for my family I'll make it work. So those are the kind of people I suspect we're going to see.

JOHN WHYTE: Should tax dollars be used? These are state funds in many places they're using to fund incentives, fund lotteries. I could argue that money could be used for other public health services as well. So is that ethical?

ARTHUR CAPLAN: True. And in fact, I'll make a prediction. We're going to see them used for other public health purposes. These lotteries seem to be having some impact on behavior. We aren't very good at persuading people to follow good public health behavior, whether it's wash your hands or put your seat belt on or whatever, or wear a helmet, that sort of thing.

Oddly enough, I'll predict the success of these incentives to getting people to vaccinate for COVID will spread out to other public health initiatives and ideas, even to other vaccines down the road.

JOHN WHYTE: Yeah. But could that cause a problem eventually? People might say I'm going to wait out because they're going to offer something free. Let me wait to the next round. And it actually could become more problematic. What's your prediction there, Dr. Caplan?

ARTHUR CAPLAN: Absolutely true. The smart calculator's like, well, that was your initial offer. How about three free meals instead of one? I like that better. So I think you're going to have to design these things.

One thing that's been missing, John, from a lot of the incentivization discussions. We have all kinds of people who are experts at marketing things and selling us things. We don't hear from them in the vaccine space I think we're going to tap their expertise, let's just say at the business schools, Tuck, Wharton, Stern at NYU. They know how to sell. They've certainly gotten me to buy a bunch of stuff I don't want by promising me all kinds of rewards that I probably don't care about, really.

But I think we could use their skill set to make this more rational. Now we're a little bit throwing it up against the wall and seeing -- I don't know, is it doughnuts, beer, lotteries, guns, fishing licenses? It's not like anybody really knows the answer. So we better study what we're doing.

JOHN WHYTE: Well, Dr. Caplan, thanks for putting it all into context for us. And inducements are not unethical as long as we follow some framework. Dr. Caplan, I want to thank you again for taking the time. You always help us break it down.

ARTHUR CAPLAN: My pleasure. Thank you.

JOHN WHYTE: And if you have any questions, drop us a line. You can email me at drjohn@webmd.net. Thanks for watching.

This interview originally appeared on WebMD on June 07, 2021

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