Entry into a million-dollar lottery for getting vaccinated against COVID-19 is Ohio’s offer to adults. Teens who get vaccinated receive a lottery ticket for state college tuition, room, board, and more. Other states are offering gift cards. Now many employers are offering rewards for COVID-19 vaccination. Businesses ranging from Krispy Kreme and Sam Adams beer to the Cincinnati Reds have announced discounts or prizes for vaccinated individuals. Are these benefit programs ethical? Are they useful? Are they better than mandates?
Incentives for Vaccination Are Ethical
Benefits or incentives for becoming vaccinated are not new. The Centers for Disease Control and Prevention now recommends exempting vaccinated people from mask requirements. Businesses like Target and Safeway have long offered coupons to customers who receive flu vaccines on site.
The ethical case for instituting vaccine benefit programs is justified by 2 widely recognized values: (1) reducing overall harm from COVID-19 and (2) protecting disadvantaged individuals.1 If benefit programs increase vaccine uptake, they directly protect recipients. By reducing transmission, increased uptake also protects the population, including ineligible children and adults, unvaccinated adults, and individuals with conditions reducing vaccine efficacy (Table). Because transmission has been higher and outcomes worse in less-advantaged communities, stemming transmission especially protects those in disadvantaged communities. In addition, costs, such as time off work for getting a vaccine or dealing with vaccine-related adverse effects, finding daycare for children, and transportation to a vaccine site, hamper access for poorer and marginalized people. Benefit programs, especially in the form of guaranteed cash payments, could improve access and increase uptake by offsetting these costs.
Table. Advantages of and Objections to Vaccine Incentives
Many benefit programs reimburse or compensate for costs related to vaccine receipt and incentivize vaccine receipt. Encouraging healthy choices through generous reimbursement is viewed as unproblematic in other health care contexts. For instance, the Affordable Care Act provides free preventive services such as other vaccines or cancer screening tests. However, just as some insurance designs go beyond zero out-of-pocket costs to affirmatively reward choices such as getting preventive care, payments that go beyond restoring the prevaccination status quo need not raise special concerns.2 Rewards often serve the dual function of incentivizing socially valuable choices and offsetting cost barriers.
Responding to Arguments Against Incentives for Vaccines
Some might argue that benefit programs coerce or exploit. This is mistaken. Offering a benefit cannot coerce because, unlike a threat, an offered benefit does not threaten to deprive someone of anything they are otherwise entitled to, a fundamental requirement to constitute coercion.3
Some argue offers of benefits exploit persons who are poor. Individuals who are less well-off may have more need for the offered benefits. But the charge of exploitation is only plausible if poor individuals are incentivized to increase their personal risks to enrich others.4 This is clearly not the case with COVID-19 vaccination, which protects recipients rather than heightening risk. Recipients get a “double benefit”: protection from disease alongside a government bond, gift card, or lottery ticket. Recognizing that incentives may be particularly compelling to poor people does not constitute taking unfair advantage of their poverty. Encouraging vaccination by offering benefits helps mitigate inequity, unlike refusing to provide benefits due to concerns about exploitation. Throughout the pandemic, some employers have offered hazard pay to recruit workers in severely affected occupations, such as bus drivers and health workers. Promising benefits for vaccinated people raises fewer concerns.
Others argue that offering benefits distorts or corrupts medical decision-making by introducing inappropriate or irrelevant motivations.5 But modest cash benefits are more likely to clear away distractions (eg, concerns about lost wages or transportation costs) and allow individuals to focus on protecting themselves and their families. Even if larger benefits were offered, financial motivations need not undermine the “moral significance” of vaccination, and in any event, such concerns should not override the imperative of stemming the pandemic. In this situation, it is important to not be hypocritical: people are paid generously for other socially valuable or personally meaningful activities like providing medical care. (And the COVID-19 pandemic illustrated that many who provide essential services are not sufficiently compensated for the value of their work.)
Lotteries more credibly raise distortion concerns because they may appeal to psychological biases. Leveraging psychological biases to encourage uptake of a safe, socially beneficial, and effective vaccine, however, seems no more an objection to a lottery than to messaging campaigns that harness biases such as loss aversion, which leads people to perceive a loss as more significant than an equally sized gain.
Others have a more fundamental objection: that medical decisions should be made without reference to an individual’s financial interests.6 Financial benefits, however, could help to focus vaccine decisions on medical factors by offsetting other costs, such as the need to take time off of work because of vaccine adverse effects. Furthermore, many medical decisions beyond vaccination have prompted efforts to promote socially preferable outcomes through financial incentives. Vaccination seems no different in this respect from smoking cessation or healthier diets, which are choices society also promotes through benefits and penalties.
Is offering benefits only to current recipients unfair to people who were vaccinated earlier?7 Entering both early and late recipients into a lottery obviates this worry. But focusing on currently unvaccinated people can also be appropriate. Earlier recipients have already enjoyed the far greater benefit of longer protection from COVID-19. Latecomers are often treated differently from early adopters. For instance, a bakery may discount bread prices before closing time to sell bread rather than give it away. Patients who appear at a clinic at a slow time may be able to make a walk-in appointment rather than having to navigate waiting lists. These practices respond to varying demand, but are not unfair.
Could people offering benefits undermine public willingness to receive future vaccines without pay? With respect to modest benefits that offset barriers to vaccination, this concern seems doubtful. Even if it has empirical merit, it must be weighed against the large benefits to society of increasing COVID-19 vaccine receipt now.
While offering benefits to COVID-19 vaccine recipients is typically ethical, it may not always be optimal. For health workers or prison guards who interact with vulnerable people and have a duty to protect them, vaccine mandates may be more ethically appropriate than leaving vaccination optional while offering incentives.
Additionally, even though benefit programs likely increase overall willingness to be vaccinated, offers of benefits may decrease willingness among specific individuals or subpopulations.8 Benefit designs should target individuals who would be responsive to benefits and avoid decreasing others’ willingness. In addition, the effectiveness of some incentives, such as vaccine lotteries, may quickly wane. In Ohio, the announcement of a lottery was associated with an increase from 15 104 people vaccinated the day before the lottery to 32 941 people vaccinated the day after, the highest number for the next 4 weeks. On June 15, only 7061 people were vaccinated.9
Despite the large social benefits of vaccination, unnecessarily large benefit payments may waste public funds.4 If almost as many people would change their position and agree to be vaccinated for incentives of $50 as $200, there is no good reason to start with $200. Overly large benefits for vaccine recipients may also invite distrust by making vaccination seem especially risky or burdensome.10 To avoid waste, benefit programs should also be evaluated for efficacy and cost-effectiveness and be rigorously compared with alternative options. Even though incentives appear to prompt surges in vaccination, programs that establish vaccination as a social norm may better sustain high vaccination rates.
It is common to thank those who perform socially valuable actions, such as by offering recognition, awards, payment, or other benefits. People who choose to be vaccinated against COVID-19 help society end the pandemic. While benefit programs that recognize or encourage their choice to be vaccinated may not always be the right approach, and may not be a sustainable approach, they are neither fundamentally ethically objectionable nor ethically unique.
Corresponding Author: Ezekiel J. Emanuel, MD, PhD, Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, Blockley Hall, Ste 1412, Philadelphia, PA 19104 (MEHPchair@upenn.edu).
Published Online: July 1, 2021. doi:10.1001/jama.2021.11045
Conflict of Interest Disclosures: Dr Persad reported grants from Greenwall Foundation and personal fees from ASCO Post and the World Health Organization. Dr Emanuel reported personal fees, nonfinancial support, or both from companies, organizations, and professional health care meetings. Dr Emanuel is also a venture partner at Oak HC/FT; a partner at Embedded Healthcare LLC, ReCovery Partners LLC, and COVID-19 Recovery Consulting; and an unpaid board member of Village MD and Oncology Analytics.
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