Governments should consider incentivising people to get a COVID-19 jab, when the vaccine becomes available, to achieve the required level of herd immunity—which could be up to 80%+ of the population—and stamp out the infection, argues a leading ethicist in an opinion piece accepted for publication in the Journal of Medical Ethics.

The incentive could be either financial or ‘payment in kind’, such as being allowed to forego the need to wear a facemask in public, he suggests.

Given the rising global death toll and the far reaching health and economic consequences of the pandemic, there have been calls, including in the UK, to mandate COVID-19 vaccination, if and when a jab is approved, points out the author, Professor Julian Savulescu, Oxford Uehiro Centre for Practical Ethics, University of Oxford.

In general, vaccination should be voluntary, he says. But there is a strong case for making any vaccination mandatory (or compulsory) if four conditions are met: a grave threat to public health; the vaccine is safe and effective; the pros outweigh the cons of any suitable alternative; and the level of coercion is proportionate.

Put simply, if voluntary schemes fail, we need to move to Vaccination Plan B, he suggests.

There are examples of coercion for the public good: conscription during wartime; taxes; the wearing of seat belts. And mandatory vaccination policies are already in place in different parts of the world, he says.

But there are ethical issues if a mandatory approach were to be adopted, he contends. So, if voluntary vaccination proves insufficient, incentivisation should be considered to address these issues while boosting vaccination uptake.

A certain level of uptake will be required to make any vaccination programme really effective and quell the relentless surge of the pandemic.

“To be maximally effective, particularly in protecting the most vulnerable in the population, vaccination would need to achieve herd immunity (the exact percentage of the population that would need to be immune for herd immunity to be reached depends on various factors, but current estimates range up to 82%),” he writes.

While there are obvious logistical issues to producing and administering a COVID-19 vaccine to the world’s population, universal coverage also faces rising vaccine hesitancy—reluctance or refusal to be vaccinated because of safety concerns.

“Vaccines are some of the safest and most effective interventions we have, and have achieved incredible successes. We no longer face diseases that killed our ancestors,” he says, “but vaccine hesitancy is on the rise even for well-established vaccinations.

“The problem is likely to be bigger for a new vaccine. For established vaccines, some countries have turned to mandatory vaccination schemes. In an ideal world, the vaccine would be proven to be 100% safe. But there will likely be some risk remaining, and there are risks that have not yet been identified.

“Any mandatory vaccination programme would therefore need to make a value judgement about what level of safety and what level of certainty are safe and certain enough. Of course, it would need to be very high, but a 0% risk option is very unlikely,” he suggests.

“So we cannot say whether a mandatory policy of COVID-19 vaccination is ethically justified until we can assess the nature of the vaccine, the gravity of the problem and the likely costs/benefit of alternatives,” he explains.

“However, another way of looking at this is that those at low risk are being asked to do a job which entails some risk, albeit a very low one. So they should be paid for the risk they are taking for the sake of providing a public good,” Professor Savulescu suggests.

‘Anti-vaxxers’ may never be convinced to change their stance, but incentivising vaccination may persuade others who might not have done so to get the jab, he says.

“The advantage of payment for risk is that people are choosing voluntarily to take it on. As long as we are accurate in conveying the limitations in our confidence about the risks and benefits of a vaccine, then it is up to individuals to judge whether they are worth payment,” he says.

Payment isn’t about coercion, he insists. “If a person chooses that option, it is because they believe that, overall, their life will go better with it, in this case, with the vaccination and the payment.

“It is true that the value of the option might exercise force over our rational capacities, but that is no different from offering a lot of money to attract a favoured job applicant,” he argues.

This is not about encouraging people to take unreasonable risks. Vaccine development and trials are in place to ensure that we are confident that there is very low risk, he emphasises.

“If a vaccine were deemed to be safe enough to offer on a voluntary basis without payment, it must be safe enough to incentivize with payment, because the risks are reasonable. It may be that those who are poorer may be more inclined to take the money and the risk, but this applies to all risky or unpleasant jobs in a market economy. It is not necessarily exploitation if there are protections in place such as a minimum wage or a fair price is paid to take on risk,” he suggests.

“A payment model could also be very cheap, compared to the alternatives,” he argues. “The cost of the UK’s furlough scheme is estimated to reach £60 billion by its [original] planned end in October, and the economic shut down is likely to cost many billions more, as well as the estimated 200, 000 lives expected to be lost as a result.

“It would make economic sense to pay people quite a lot to incentivize them to vaccinate sooner rather than later—which, for example, would speed up their full return to work.”

There are precedents for paying people to perform their civic duty: for example, blood donations are paid for in several countries, and while the UK doesn’t pay donors directly, it does import blood from countries that do, he points out.

Incentives could also take the form of ‘payment in kind,’ he suggests. “One attractive benefit would be the freedom to travel, to not wear a mask in public places if you carried a vaccination certificate, and not to socially distance,” he suggests. “Moreover, it would help ameliorate the risks the unvaccinated would pose to others.”