November 5, 2020

expert reaction to opinion piece suggesting governments should consider incentivising people to get a COVID-19 vaccine when one is available, such as by paying them

An opinion piece published in the Journal of Medical Ethics suggests governments should consider incentivising people to get a COVID-19 vaccine when one becomes available, in order to achieve the required level of herd immunity.

Prof Adam Finn, Professor of Paediatrics, University of Bristol, said:

“This paper discusses possible approaches to implementation of COVID vaccination once one or more vaccines become available.  The proposal to make immunisation mandatory and the approach preferred by the author to offer financial incentivisation to people to accept the vaccines runs counter to the normal approach taken in the UK which is to offer vaccines free on the NHS and for people to take them voluntarily.  It is likely that vaccines will initially be offered to people at high risk of infection and disease and that demand will exceed supply.  One hopes that thereafter, once there is general experience of vaccine use, others who are offered immunisation will wish to accept it in the usual way.  Time will tell but it would be much better to avoid the need to adopt either of the approaches suggested.

“With regard to the suggestion that immunised people might be told they do not need to wear masks, this could be very problematic.  No vaccine provides 100% protection and vaccines will need to be used in conjunction with rather than instead of other measures at least in the early months of their deployment.”

Prof Helen Bedford, Professor of Child Public Health at UCL, and Dr David Elliman, Consultant in Community Child Health, both said:

“One of the interventions to control the current COVID-19 pandemic would be a safe and effective vaccine.  It is unclear how advanced trials are and in particular, how effective the candidate vaccines might be.  Antibody levels do not necessarily correlate with protection and if there is protection, we don’t know whether it will protect against infection, serious infection and/or death. In addition, we don’t know how long any protection will last.

“Adults may be hesitant about whether they would accept a vaccine and Professor Savulescu discusses mandation and incentives to increase uptake.  The discussion is a useful stimulus to further consideration, but there are some points with which we would take issue.

“Popular views about vaccines vary around the world and in UK, there is a high uptake of vaccines in general.  Any suggestions aimed at increasing vaccine uptake, must take into account the particular population in question.  Blanket interventions may not work and can be counter-productive.  Mandation, in particular, may turn immunisation into a civil liberties issue and people may object on the grounds of being told what to do, without any specific objections to the particular vaccine on question.  The evidence that mandation, per se, results in increased uptake is weak.  The introduction of mandation is usually accompanied with improved information materials and assurance that access is made readily available.  These, of themselves might be the explanation for the increased uptake seen.  The analogy with conscription is used.  It is not a good analogy as many countries allow for conscientious objection.  If the analogy is to be pursued, presumably the same would apply to vaccination?

“Professor Savulescu then discusses awarding incentives.  It is stated that this “would require government to be transparent, explicit and comprehensive in disclosure of data, what should be inferred and the limitations on the data and confidence”.  Don’t we always require that, whatever the issue?

“Prof Savulescu suggests incentives could be monetary or ‘in kind’.  In a time when many people are out of work or their jobs are threatened, any source of income may be attractive and so while it would not be compulsory, it is likely that financial pressures would operate, i.e. where will I get the money to pay the rent, find food for the children, etc.  Just because the same applies to risky and unpleasant jobs, doesn’t mean it is correct.  In any case , in reality, the most unpleasant jobs are often the most poorly paid.  Incentives in kind that are suggested are greater freedom to travel, opportunity to work or socialise and relaxing the necessity to wear a mask.  It is highly unlikely that we will know exactly how effective a vaccine is in preventing spread of the disease in the early stages, and until we do know, it would be dangerous to offer these incentives.

“Before any form of mandation or incentive is even considered it is important to ensure that everything else needed to control the infection is in place, for example effective testing and tracing systems and policies around isolation and quarantine.  Apart from flu vaccine for healthcare workers there is little experience globally of mandating vaccines for adults and even less experience of providing incentives.  One could argue that a better use of the resources that would be required to provide incentives or mandation should be put into encouraging uptake of any COVID vaccine, by full and transparent communication, and ensuring easy access to vaccination services.”

Prof Keith Neal, Emeritus Professor of the Epidemiology of Infectious Diseases, University of Nottingham, said:

“Paying people to get vaccinated would set a very dangerous precedent.  The main benefit of vaccination is to protect yourself.  Any herd immunity from vaccines is a bonus for those unable to be vaccinated.

“If we did this, people will expect it for other vaccines and also social media falsehoods would have a field day suggesting it can’t be safe if that’s what you need to be paid to have it.

“Using vaccines as immunity passports would be worthless as the vaccine may occasionally not protect and they system could be open to forgeries much the same as under 18s borrow ID for alcohol.

“We have never had mandatory vaccination and are not going to start with a new vaccine.

“I suspect demand will exceed capacity of vaccine production/delivery.

“We would need about 80% or higher vaccine coverage assuming the vaccine is not 100% effective.  The main aim will be to initially protect those at risk of serious COVID-19, that is the elderly and those with severe underlying other diseases that increase their risk.

“If the vaccine only protects but does not interrupt transmission, only those vaccinated will be protected so we need to aim for full coverage of those at risk.

“RCTs help to determine safety by looking at complications in those who have the vaccine and those that don’t.  Events happen to people whether they are in a trail or not.  The important issue is that many thousands have received the vaccine safely and the risk of death from COVID-19 infection for a 60 year old man is over 1%.  The maths is easy.

“The idea to pay people to get a vaccine is ill thought out and potentially counter-productive.  The money will be much better spent in other parts of the NHS or providing vaccine to low income countries to prevent possible re-introduction into the UK.”

‘Good Reasons to Vaccinate: Mandatory or Payment for Risk?’ by  Julian Savulescu was published in the Journal of Medical Ethics at 23:30 UK time on Thursday 5 November 2020.

Declared interests

Prof Adam Finn: “No conflicts.”

Prof Helen Bedford and Dr David Elliman: “We have no conflicts of interest.”

Prof Keith Neal: “I will not hesitate to have the vaccine when I am offered it.”