Is it ethical to offer lottery entries in exchange for people to get vaccinated? What about prize money? How about taking things away if they don’t?
As the delta variant complicates the recovery from the pandemic, and health officials seek ways to convince people to get vaccinated, many incentives are emerging. In Illinois, the Department of Public Health has offered $7 million in cash prizes and $3 million in scholarships. In recent weeks, prizes went to residents in Chicago, Quincy, Springfield, Berwyn and Joliet. Recently, the Chicago health department announced they will offer $25 Visa gift cards for those vaccinated at home.
In general, it is ethical to offer a modest prize, said Craig Klugman, co-director of DePaul University’s Bioethics and Society program and a professor of bioethics and health humanities.
A July article in the American Medical Association journal examined the ethical considerations of offering gift cards, a million-dollar lottery entry or college tuition and room and board. The authors, Govind Persad, a law professor at the University of Denver, and Ezekiel J. Emanuel, a professor of medical ethics and health policy at the University of Pennsylvania, evaluated issues ranging from fairness to whether it may spur mistrust or make people not want to get vaccinated without payment in the future.
Ethicists say it depends on how incentives are offered.
First, the amount of a cash or prize offered matters. Klugman said a concern is whether the cash nudges someone to get the vaccine who already was planning to, or whether the incentive is the entire and whole reason for getting it, which drifts closer to coercion.
“In motivating, you are encouraging someone to do an action that they were going to do anyway. We nudge them to act sooner,” Klugman said. “This is ethical since no one is changing a person’s mind or forcing them to do something they weren’t planning to do.”
But something like, hypothetically, offering free college tuition is more problematic, he said. “Could the person still walk away from the prize? Yes, but the prize is so great that it’s hard to walk away.”
In short, he said, “It’s ethical to offer a modest incentive that pushes someone off the fence and moves them to act sooner than they might have, but it’s not ethical to coerce them to acting in a way that they would not have without the prize.”
Ethically, it also depends on how things like lotteries are set up, said Jeffrey Kahn, director of the Johns Hopkins Berman Institute of Bioethics. “If everybody who’s been vaccinated gets put into the lottery, that seems to be a better approach than if starting today, those who sign up to get vaccinated get entered into a lottery. Because then you effectively punish the people who were responsible earlier in the pandemic.”
Although the Illinois lottery includes everyone who has been vaccinated, the Chicago Visa gift card program is for the newly vaccinated. The city has also promoted incentives like Grubhub gift cards and tickets to Six Flags and Lollapalooza, according to a statement from the city’s Joint Information Center, which added, “We’re always evaluating our vaccination strategy to look for new and creative ways to increase coverage across the city.”
Offering incentives to people who sign up later might send a message that it’s worth it to wait, Kahn said. “It starts to send the wrong message, which is wait until the stakes are higher and maybe you too will get an incentive.”
The JAMA article’s authors noted that earlier recipients get the benefit of longer protection from the virus. The authors likened offering things to the unvaccinated to a baker discounting bread prices before closing time or patients who appear at a clinic at a slower time having a shorter wait. “These practices respond to varying demand, but are not unfair,” the authors write.
In general, incentives are not a problem, nor are they a novel thought. “I think it frankly costs money to do all kinds of programs to get people vaccinated, and I think it’s just another tool in the toolbox,” Kahn said.
As a parallel, Kahn noted that money is used as an incentive to get people into clinical trials. And the JAMA authors noted that the Centers for Disease Control and Prevention’s previous recommendations exempting vaccinated people from mask requirements could be considered an incentive; business like Target and Safeway offered coupons to customers coming in for a flu vaccine.
The JAMA article noted cash payments can offset vaccine-related barriers like finding daycare or transportation to a vaccine site. “Rewards often serve the dual function of incentivizing socially valuable choices and offsetting cost barriers,” the authors write.
But Kahn said it’s not surprising for people, especially those who got vaccinated as soon as possible and now feel they are watching the results of other people not getting vaccinated, to question these efforts.
Even his own mother asked him if these incentives were bribery, he said. He explained that it’s not. “Bribery is to get you to do something unethical by some kind of illegal payment,” he said. “Giving someone an incentive to go get vaccinated during a public health emergency of pandemic proportions is not bribery.”
Mandates, on the other hand, summon different ethical layers.
If you mandate vaccination without exceptions, that can become punitive, Kahn said. He noted that employers and universities are weighing vaccine mandates. At Johns Hopkins, exceptions exist right now for medical, religious or philosophical reasons, but people have to make their case.
In general, exceptions are included and should be, he said. “It’s one thing to give people an incentive, it’s another thing to require them,” he said. “Incentives are never punitive.”
Alison Bowen, Chicago Tribune