Anya Kamenetz recently wrote an article, “Bribing the Poor”, about Esther Duflo’s strategy of giving the poor incentives to be immunized. While the article mainly just reported on the practice, it did get me thinking about the ethics of this approach. But before getting to the moral matter, a little background is in order.
In developed countries, about 90% of children receive immunization. This has had a significant impact on the health of the population. In contrast, less-developed countries tend to have far lower immunization rates. For example, India has an overall rate of 44%, but specific areas have rates that drop to 22% or even 2%. While humans can have natural resistance to diseases, the lack of immunization means that people get sick (and sometimes die) needlessly.
Duflo focused on India, and hence the best information is available for that country. Duflo found that there were various obstacles to immunization. The first is that many clinics in the rural area Duflo studied were closed because the government paid nurses did not show up for work. The second is superstition. Many people still believe in supernatural causes of illness and such people will tend to not put much faith in immunization (unless, perhaps, it was presented as magic-something that Duflo did not propose). The third is that immunizations have an image problem. When they work, there is nothing to see. When they do not work or they cause a harmful effect, the results are visible and tend to stick in people’s minds. People then tend to “reason” that immunizations are harmful in general, thus falling victim to misleading vividness, hasty generalization or the fallacy of anecdotal evidence. This is not, of course, confined to the developing world. In the United States unfounded fears about vaccination causing autism caused people to forgo immunization for their children. Irrationality, like disease, is a global phenomenon. The third is that getting immunization can require effort. The fourth is that a clear and obvious incentive (other than avoiding disease) was not provided.
Duflo’s solution involved two parts. The first was aimed at making immunization easy. This was done by setting up camps in villages. To ensure that the nurses showed up, they were paid only when they did so. This provided the nurses with a financial incentive to actually do their jobs. Making it easier to get the shots boosted the rate of immunization from 2% to 18%.
The second part was aimed at giving people a clear incentive to get immunized. As many thinkers have noted, people tend to place less value on the future and also seem to find a negative (not getting disease) less appealing than a positive (a gain, such as a gift). As such, the incentive to get immunization that will prevent something from happening latter will tend to be relatively low. However, an incentive that involves getting something right now will tend to be more effective. Duflo’s solution was to offer a $1 bag of lentils as an incentive to get one’s child immunized. This tactic increased the immunization rate from 2% to 38%, which is certainly a significant boost. As an added bonus, the overall cost was lower: the nurses are paid by the hour, so more people were immunized in less time.
While this seems like a very sensible approach, people on both the left and the right have attached it as unethical (which might be taken as evidence in its favor).
People on the left tend to advance the argument that bribing the poor to get immunized is patronizing and paternalistic. To use an analogy, it could be compared to giving a child a treat so she will cooperate and get her shots. While this is fine with an actual child (they do not know better), it might well be regarded as condescending paternalism that casts the poor as children who must be bribed to do what a rational person would do without a bribe.This would seem to be wrong.
While this does have some appeal, it can be countered. One reply would be to follow John Stuart Mill’s view: “Despotism is a legitimate mode of government in dealing with barbarians, provided the end be their improvement, and the means justified by actually effecting that end.” Swap out “paternalism” for “despotism” and keep the appeal to consequences, and this would be a possible approach. After all, the good that is done for the children and others would seem to outweigh any harm done by giving people an incentive to get immunized.
A second reply is that this incentive approach need not be paternalistic. After all, offering people an incentive hardly seems to be inherently patronizing. To use an example, students might be offered extra credit to go to an event that would benefit them. This hardly seems paternalistic. Or, to use another example, companies often provide free stuff at expos to get people to look at their goods and services. That hardly seems patronizing. Another point worth considering is that people do not claim that paying the nurses to give the immunizations is patronizing. If paying the nurse to do her duty is not patronizing, then paying the people to do their social duty is not patronizing either.
On the right, the usual objection is that the poor should be responsible and should not be given a handout. As a moral argument it does have some appeal. After all, bribing someone to do what they should do because it is right does seem to be morally questionable (at least on some grounds). To use an analogy, if a person is given $1 when she tells the truth and tells the truth for the sake of the money, then she is not acting on the basis of morality. The person who bribes her might have good intentions, but s/he can be seen as acting wrongly, at least some views. For example, Kant would regard this in a rather negative light: for him, people are supposed to do good out of a sense of duty rather than a desire for gain.
Despite the appeal, this can be countered in various ways. One obvious way is to argue on utilitarian grounds: handing out free lentils with the free immunizations ends up preventing the harms of illness and death. Put in the financial terms so beloved to the right, it is a good investment in terms of the money saved on later medical care and the worker productivity that would be lost to illness and death. A second way to argue it is that while the parents are being bribed to do the right thing, the folks on the right should be more worried about the children than the adults. While it might be wrong to bribe parents to get their children immunized, it would be worse to allow children to go without immunization. As such, while it might be claimed that the parents have acted wrongly, it would seem that the people doing the bribing have acted rightly. Finally, the folks on the right should appreciate the value of providing financial incentives to get people to do things. After all, that is what capitalism is all about.
In light of the above arguments, bringing the poor in this manner seems to be morally acceptable.