Money, vial, and syringe.

Payments for COVID-19 Vaccination: Ethical and Legal Considerations

By Govind Persad

Should we pay people to receive COVID-19 vaccines?

Paying patients to receive medical interventions, such as vaccinations, raises legal and ethical issues. I explored these concerns in depth in a 2018 Yale Journal of Law and Technology article, “Paying Patients: Legal & Ethical Dimensions.”

This post summarizes key points from the article.

People have been paid to make medical decisions that benefit society, including:

and, most relevantly, for receiving influenza and Hepatitis B vaccination.

Why aren’t these payments more common? One answer: ethical discomfort. One study concludes that “though financial incentives seem to be an effective strategy for enhancing medication adherence, there is no appetite among clinicians to use them in practice,” and another reports that many providers viewed these payments as unethical.

Ethical objections to paying people for socially beneficial health choices, such as vaccination, have a variety of conceptual underpinnings:

Coercion. Some believe payments coerce. But payments don’t threaten to deprive offerees of anything they’re entitled to have.

Undue Inducement. Some believe payments unduly induce because they distort perceptions of risk and benefit. But there’s little evidence payments have this effect. Alternatively, some believe they unduly induce by getting offerees to do something they wouldn’t otherwise have done. But then almost every payment, including salaries and travel reimbursements, unduly induces.

Deliberative Insulation. Still others believe that people should make health choices in a way that’s deliberatively insulated from financial motivations—they “should reflect the values of the individual concerned and nothing else,” or be made for “the right reasons, and money is not always one of those reasons.” Perhaps some choices are like this, although people consider financial outcomes when making even very important choices, like where to live and work. But is vaccination a choice that must be so insulated? And, if payments work, should we be willing to accept fewer vaccinations in order to achieve better “deliberative insulation”?

Exploitation. Some believe payments unfairly take advantage of poorer offerees. But this is unlikely, because individuals usually gain as much or more than society does from vaccination.

Disrespect. Others believe payments communicate disrespect. But this is very contextual: it may be rude to tip your teaching assistant, but rude not to tip your bartender. We often reimburse people for costs or reward them for valuable social contributions.

Deservingness. Many complain that payments for socially beneficial health behaviors are unethical because they “pay people for what they should be doing anyway.” But we reward people for doing what they should do all the time, ranging from charitable tax deductions to CrimeStoppers rewards.

IncentiveSeeking. Some worry that “By introducing payment, voluntary adherence will disappear. Why should patients agree to take medicines for nothing if they can be paid?” This is an empirical question, worthy of study. But many people will likely keep making medical choices that benefit society, because those choices also benefit them.

The more important ethical question is about effectiveness: do payments work to increase vaccine uptake? The data on influenza and Hepatitis B vaccine uptake suggests that payment increased uptake. In contrast, studies disagree about whether Ohio’s lottery program increased uptake, and there is little work so far evaluating other state lotteries. Some states and localities have used payments other than lotteries, like savings bonds or gift cards: these should be evaluated as well.

Last, payments present a few legal questions. First: are they taxable? Probably, but not as employment income. Second: do they illegally discriminate against vaccine refusers? Under federal law, small payments don’t: larger payments by employers present more complicated questions, and the CDC has limited the use of some incentive funds to $25/person (though not explained why). But a raft of new state laws limiting vaccination-based policymaking might classify payments to the vaccinated as illegal discrimination, though this depends on how the laws are worded.

Govind Persad

Professor Persad’s research interests center on the legal and ethical dimensions of health insurance, health care financing (both domestic and international), and markets in health care services, as well as professional ethics and the regulation of medical research. He has been selected as a 2018-21 Greenwall Faculty Scholar in Bioethics for an ongoing research project on health insurance and protection against financial risk. His articles have appeared or will appear in the George Washington Law Review, Emory Law Journal, Boston College Law Review, and Yale Journal of Health Policy, Law, and Ethics, among others. He was selected as a Health Law Scholar in 2017 and as a BioIP Scholar in 2018 by the American Society of Law, Medicine and Ethics.

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