When I received my first dose of Pfizer’s COVID-19 vaccine last December, nobody paid me to roll up my sleeve. Yet, as vaccination efforts approach an expected tipping point, at which the amount of available vaccine exceeds the number of willing recipients, with the rate of vaccination far below the threshold required for herd immunity, paying people to take their shots likely offers our society’s best chance at stemming the pandemic.
Private employers — including American Airlines, Marriott and Dollar General, have already taken the lead in this regard — but payouts are generally low: an extra day off or a few hours pay. The sooner the government starts offering larger cash incentives to the public the safer all of us will be; former Maryland Congressman John Delaney has proposed $1,500.
Financial incentives have been shown to be highly effective in persuading patients to obtain a wide range of medical services, from complying with treatments for tuberculosis and hypertension to attending weight loss programs and showing up for post-partum medical appointments. Give parents cash coupons, and they even more prove willing to take their children to the dentist. Programs that spend taxpayer dollars paying people to act in their own best interest may strike some as unfair. Yet in a medical system where we pay for each other’s poor health choices indirectly in the long run, either through Medicare, Medicaid or elevated private insurance rates, paying people to stay well today can spare society costs in the future. Incentivizing smokers to attend tobacco cessation programs now, for instance, is likely far cheaper than paying for their chemotherapy later.
Concerns have been raised by bioethicist Nancy Jecker and others that such payments are coercive. I agree. That is the whole point. Coercion is not inherently unethical. For example, if I park in front of a fire hydrant, the city will tow my car; if I do not show up for work, my employer will stop sending me a paycheck. Coercion becomes problematic only when it infringes upon some vital liberty or imposes unfair risks on some groups more than others. Paying people to act in ways that will save their lives, and protect their neighbors, does neither. Of course, those with less money may prove more motivated to accept cash to get vaccinated, but that’s a desirable result if it saves the lives of more indigent people.
Legally, the government can compel people to get vaccinated. This principle was established by the United States Supreme Court in 1905 and has been upheld consistently ever since. Doing so would also be ethically justifiable to protect the small number of individuals for whom vaccination proves ineffective. More important, sizable unvaccinated populations increase the risks of new coronavirus variants that could render vaccines ineffective — thus threatening the lives and livelihoods of us all.
In our nation, one generally has a right to control what enters one’s body. But nobody has the right to drive after consuming alcohol, because doing so threatens others. Yet COVID-19 has killed approximately 50-times the number of Americans as intoxicated drivers have since last March — and a novel variant could kill many more. It is a perverse notion of liberty that gives people the right to infect their neighbors with a deadly disease.
Compulsory vaccination is unlikely to prove workable in the United States. Jailing or fining objectors would lead to massive resistance. In contrast, offering people a tax credit if they are vaccinated is unlikely to generate civil disobedience. That is not to say every vaccine-resistant citizen will roll up his sleeve for a check, but that’s OK: 100% vaccination is an unrealistic goal. But there likely is a price that could persuade enough of the hesitant or indifferent to reach the threshold needed for herd immunity. If we don’t pay up soon, we may find ourselves paying the price of inaction soon enough.
(Jacob M. Appel is director of Ethics Education in Psychiatry at the Icahn School of Medicine at Mount Sinai. He is the author of “Who Says You’re Dead?” a collection of ethical conundrums.)
