Some shelter users in Yellowknife were offered $20 to get the vaccine. Was that ethical?

People who use the day shelter and sobering centre in Yellowknife — who are currently at the heart of a COVID-19 crisis in the N.W.T. — were given a $20 "token of appreciation" in exchange for being vaccinated early on in the territory's vaccination campaign, says the head of the NWT Disabilities Council.

"We understood the extreme vulnerability of this population and how they would be negatively impacted health-wise due to many having conditions listed as high risk," wrote Denise McKee, the executive director of the disabilities council, in an email to CBC News on Tuesday.

"It was also to help protect health services and resources as we understood if this population became ill, they would likely need hospital services." 

Now, that's exactly what the territory is dealing with. 

The day shelter and sobering centre in Yellowknife — operated by the disabilities council — was closed indefinitely over the weekend after a number of staff and clients tested positive for COVID-19. 

The COVID-19 secretariat said it would no longer be publicly reporting the number of people who are underhoused who have tested positive for the virus or who have been hospitalized. Dr. Kami Kandola, the territory's chief public health officer, said on Tuesday however, that more than 70 people who are underhoused or who work to support people who are underhoused had tested positive.

80+ vaccinated in single day

The vaccine incentive program was quickly quashed by the Northwest Territories Health and Social Services Authority (NTHSSA). McKee said it was offered on the first day vaccines became available to service users, and more than 80 were vaccinated in the single day it ran. 

Those who attended, she said, "felt grateful that they had the opportunity to be vaccinated, when many other places didn't have the opportunity."

Ali Kincaid, a manager of cabinet communications, told CBC News in an email the NTHSSA became aware of the incentive program early in the territory's vaccination campaign and asked that it be discontinued "because of the grey area surrounding the ethics of such practices." 

"Though incentives are a long-established and useful tool in public health promotion activities, the GNWT [Government of the Northwest Territories] did not have a clear position on such practices in relation to COVID-19 vaccination at that time," she wrote. 

The cash, according to McKee, came from the disabilities council and was given as a token of appreciation to service users for "keeping their community and themselves safe."

The idea stemmed from seeing similar incentive programs in Nunavut, she said. 

The municipality of Arviat, Nunavut ran a lottery in January where residents who received a COVID-19 vaccine were entered to win one of five $2,000 prizes. Alberta, meanwhile, is currently offering a $100 debit card to those who receive either their first or second dose.

McKee said the disabilities council chose to give out cash, instead of running a lottery, because of the negative impact a large sum of money might have. It also helped ensure service users waited for 15 minutes after receiving the injection so they could be monitored for potential adverse reactions, she wrote. 

"All individuals consulted privately with the health professionals and made the decision to proceed or not to proceed."

$20 incentive legitimate, says one ethicist

Nicholas B. King, an associate professor in the biomedical ethics unit and at the epidemiology, biostatistics and occupational health department at McGill University told CBC News there are two ethical considerations to be made when deciding whether to offer vaccine incentives.

The first question to consider, he said, is whether the financial incentive would encourage someone to do something that would cause them harm, risk their health, or infringe on their freedom of choice. The second is whether offering a financial incentive would be disproportionately burdensome or coercive to people who are particularly disadvantaged.

King, who studies and teaches a course on public health ethics and policy, believes the situation at hand — paying people who are homeless $20 to get vaccinated — is a legitimate use of a financial incentive. 

"It reduces the risks for the whole population — the more people who are vaccinated, the closer we are to achieving herd immunity and the less community transmission you're going to have — and it reduces risk for the individual." 

King acknowledged there are a few potential risks to taking the vaccine but said that "every piece of evidence we have shows that taking the vaccine incredibly reduces your risk of a severe consequence, catching COVID-19." 

King also believes $20 would not be burdensome to people in shelters. 

"I would say this is not a life-changing amount of money. This is not $10,000 dollars. This is not an offer you cannot refuse." 

However, King said it's hard to pinpoint what cash figure would be too big because "financial incentives work differently on different people, and they're more coercive to people who have less money to begin with." 

The dollar value should act as a "nudge" not a "shove," he said.

"The thing you have to weigh, to a certain extent, [is that] a financial incentive is coercive … $20 may be marginally coercive, but it is coercive."

Arguments against incentives

Financial incentives and disincentives, said King, are nothing new in the realm of public health. 

A so-called "sin tax" applied to products like tobacco or alcohol are accepted as a legitimate use of financial disincentives to encourage people against behaviour that's bad for their health, while subsidies for gym memberships, healthy foods, exercise and green space incentivize people to do things that are good for their health, he said. 

Two common arguments against vaccine incentives, King said, are that it's unfair to people who willingly received the jab and that sets a bad precedent for the future. 

"On the question of fairness, well it's not just protecting the individual …  whatever we can do to maximize vaccination rates is a legitimate public health goal," he said.

He also hasn't seen any evidence that offering a financial incentive will encourage people to hold out in the future. 

King also addressed another argument that pertains specifically to offering vaccine incentives for people who are marginalized and likely to be dealing with poverty, mental health issues and trauma. 

"One criticism would be, why are we paying them to get a vaccine that does protect them but is sort of mostly intended to protect everyone else, when we should be treating their underlying health issues?"

King said he understands that argument, but doesn't feel it applies in this case. 

Vaccines are one of the services available to people at the temporary isolation centre set up at the Quality Inn and Suites, where clients are also offered food, COVID-19 testing, and a managed alcohol program. 

The territory has supported communities to offer vaccine promotion activities, Kincaid said in her statement, but none of them have involved directly giving people cash in exchange for being vaccinated.