Covid-19: Should people be paid to get vaccinated?

  • Although trials are still underway, Covid-19 vaccines are expected to roll out as early as next year
  • However, vaccine hesitancy is escalating in populations around the world
  • A leading ethicist suggests that offering incentives may be the answer

Global surveys have been showing worrying signs of Covid-19 vaccine hesitancy – the reluctance or refusal to be vaccinated due to safety concerns.

For scientists, this only adds to the existing stress of trying to control the pandemic, given that the safest way to reach herd immunity, or “herd protection”, is through an effective vaccine.

However, according to leading ethicist, Professor Julian Savulescu from the Oxford Uehiro Centre for Practical Ethics, University of Oxford, incentivising people to be vaccinated, if one becomes available, may be the solution.

Savulescu, whose opinion piece was peer-reviewed and published in the Journal of Medical Ethics, says that to obtain the necessary level of herd immunity – which could be just over 80% of the population – an incentive (either financial or "payment in kind"), must therefore be considered by governments worldwide.

An incentive in kind, for instance, is allowing people the “freedom to travel, to not wear a mask in public places if you carried a vaccination certificate, and not to physically distance", he writes. 

Understanding herd immunity

Herd immunity, as explained by Nature, occurs when a virus can’t spread as it keeps encountering people who are protected against infection. The form of protection is typically discussed as a result of widescale vaccination programmes.

When a sufficient proportion of the population is no longer susceptible to infection, the virus gradually fades out. It also protects those who can’t receive or sufficiently respond to the vaccine, such as the elderly and those with compromised immune systems.

“You don’t need everyone in the population to be immune — you just need enough people to be immune,” Caroline Buckee, an epidemiologist at Harvard T.H. Chan School of Public Health in Boston, Massachusetts, told Nature.

Strong case can be made for mandatory vaccination

In his paper, Savulescu states that vaccination should generally be voluntary, but there are instances where a strong case can be made for making a vaccination mandatory, if four conditions are met: 

  • A grave threat to public health 
  • The vaccine is safe and effective 
  • The pros outweigh the cons of any suitable alternative
  • The level of coercion is proportionate

An example of coercion that happens for the public good include the wearing of seat belts, he says. He also makes the point that mandatory vaccination policies are already in place in some parts of the world.

"To be maximally effective, particularly in protecting the most vulnerable in the population, vaccination would need to achieve herd immunity (the exact percentage of the population that would need to be immune for herd immunity to be reached depends on various factors, but current estimates range up to 82%)," he writes.

Safety issues

Vaccine hesitancy, he contends, is likely to be bigger for a new vaccine.

“In an ideal world, the vaccine would be proven to be 100% safe. But there will likely be some risk remaining, and there are risks that have not yet been identified.

"Any mandatory vaccination programme would therefore need to make a value judgement about what level of safety and what level of certainty are safe and certain enough. Of course, it would need to be very high, but a 0% risk option is very unlikely," he maintains, further commenting:

"So we cannot say whether a mandatory policy of Covid-19 vaccination is ethically justified until we can assess the nature of the vaccine, the gravity of the problem and the likely costs/benefit of alternatives.

'Paying people is not coercive'

“However, another way of looking at this is that those at low risk are being asked to do a job which entails some risk, albeit a very low one. So they should be paid for the risk they are taking for the sake of providing a public good," Savulescu suggests.

While anti-vaxxers may never be convinced to change their stance, incentivising vaccination may persuade others to be vaccinated, he says.

"The advantage of payment for risk is that people are choosing voluntarily to take it on. As long as we are accurate in conveying the limitations in our confidence about the risks and benefits of a vaccine, then it is up to individuals to judge whether they are worth payment," he says.

He also believes that payment isn't about coercion: “If a person chooses that option, it is because they believe that, overall, their life will go better with it, in this case, with the vaccination and the payment.”

More than this, Savulescu makes the point that there are existing precedents for paying people to perform their civic duty, such as remuneration for blood donation in several countries, including the US, Germany, and Austria

Incentivisation: overriding our rational capacity?

Although it may be true that the value of the option of incentivisation might exercise force over our rational capacities, Savulescu argues that is no different from offering a large sum of money to attract a favoured job applicant, for instance.

In fact, he insists that this option is not about encouraging people to take unreasonable risks, as one has to bear in mind that vaccine development and trials go through rigorous safety testing and won’t be released until it is known to be low-risk.

"If a vaccine were deemed to be safe enough to offer on a voluntary basis without payment, it must be safe enough to incentivise with payment, because the risks are reasonable. It may be that those who are poorer may be more inclined to take the money and the risk, but this applies to all risky or unpleasant jobs in a market economy. 

“It is not necessarily exploitation if there are protections in place such as a minimum wage or a fair price is paid to take on risk," he believes.

Incentivisation versus the alternative: which will cost less?

"A payment model could also be very cheap, compared to the alternatives," Savulescu argues.

"The cost of the UK's furlough scheme is estimated to reach £60 billion by its [original] planned end in October, and the economic shut down is likely to cost many billions more, as well as the estimated 200 000 lives expected to be lost as a result.

"It would make economic sense to pay people quite a lot to incentivise them to vaccinate sooner rather than later – which, for example, would speed up their full return to work."

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