Ethics of ‘nudges’ for the vaccine hesitant pose many questions

While The Ohio State University reports a complete or partial COVID-19 vaccination rate of 93.3%, the state of Ohio’s rate is much lower: About 60% of state residents report receiving their first shot and only 57% completing the entire vaccine series. Public health officials still grapple with the hesitance that many experience with the COVID vaccines.

During a discussion titled “Nudging the Vaccine Hesitant,” a panel of experts gathered to weigh the efficacy and ethics of public health “nudges,” small interventions that may push people into a specific action, in the COVID-19 pandemic. The event, hosted by the Center for Ethics and Human Values (CEHV), featured Mark C. Navin, professor of philosophy at Oakland University, Kristen Carpenter, assistant professor of clinical psychiatry and behavioral health in Ohio State’s College of Medicine, and Myriam Shaw Ojeda, assistant professor of pharmacy practice and science in the College of Pharmacy. The event was organized by Trevor Hedberg from CEHV and the College of Pharmacy.

“Some nudges, in some contexts, can be very effective,” Navin said. A complicator in the case of the pandemic, however, is that there is a disagreement about whether vaccines are a public health matter or one of individual health. In the case of individual health, the chief value is informed consent.

This is where the issue of nudges becomes more complex, said Shaw Ojeda. If nudges are meant to be small interventions, how informed can a patient truly be?

“How do we work with people in a way that promotes equity or does not infringe on a person’s ability to make a decision? How do you educate a patient fairly?” she asked.

In addition to questions about informed consent, the panel considered how effective nudges have been since the pandemic began. One example is the state’s Vax-A-Million sweepstakes, where vaccinated Ohio residents were entered into a weekly lottery for the chance to win $1 million or a college scholarship.

“I was in a meeting a week after the lottery was announced and we saw a spike,” said Shaw Ojeda, who worked on the state’s vaccination campaign. “We saw a spike in vaccine uptake but that spike was not sustainable. It lasted for the duration of the program and then it went away.”

While the gains these programs make are not sustainable, Carpenter was quick to say that even a small increase in the vaccination rate is meaningful for the state and the country.

“1%, 2%, 3%, we’re still talking about millions of people,” she said. “I don’t think we should dismiss these small gains. If you can’t celebrate, it’s too hard. So if I see that even one person has made the choice to get vaccinated, fantastic.”

All three panelists mentioned the polio vaccine and how it is considered a highly successful vaccine rollout. Navin was skeptical of this assessment.  

“There’s good reason to think that there was a lot more socialization toward conformity, towards obedience,” he said. “We lived in an especially white, suburban, middle-class life where both political parties were not polarized. And so we had a sort of bipartisan conformity in the culture.”

Carpenter agreed, suggesting that the polio vaccine would encounter the same problems the COVID-19 vaccine does today, due in large part to mistrust of public health officials.

“There is misinformation and distrust of the system,” she said. “And some of that distrust is warranted when you think about what has been done to various communities, in medicine. But I think [during the polio epidemic] there was trust that the government would do right by the public. … I don’t know that we have the tools to combat that now.”

Shaw Ojeda agreed that some communities had good reason to question public health measures in the past, adding that trust must be rebuilt, especially with historically disadvantaged groups.

“We are going to deal with this pandemic for the immediate future,” she said. “Hopefully it will pass but, in the meantime, what are the lessons we’re learning here?”