Bribing the Poor

Esther Duflo at Pop!Tech 2009

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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.

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11 Comments.

  1. It not only works as an incentive, but also as an epistemic fact finding device.

    Duflo is an economist. It’s a normal way of thinking for an economist to reveal the strength of someone’s preference by seeing the value of what they will accept to give up acting on it. Duflo’s thesis was that the reluctance of many parents to immunize their children was based on relatively trivial and weakly held preferences – like inconvenience – rather than deep religious beliefs. This thesis seems corroborated since even very poor people would not give up a deeply held fundamental conviction for a dollar worth of food.

    Note that this would not hold if the bribe was much larger – one hundred dollars say – at which point very poor people might really be being forced to choose between individual conscience and the well-being of their family. That should raise quite significant ethical concerns.

  2. Dear Beard,

    The value of a 1 kg bag of raw lentils to the poor in India is, perhaps, not best expressed by pointing out that it only costs a $1. A 1kg of raw lentils may indeed mean a great deal more than a $100 might mean to many Americans. Thus the bribe might force the very choice between individual conscience and the well being of their family that you suggest a $100 bribe might provoke.

    Obviously enough individual conscience frequently gets in the way of the well being of many a family.

  3. Why call it a “bribe”?

    If you call it an “incentive” or a “reward”, the problem evaporates.

    For example, a parent rewards his child with an excursion or a trip if he or she gets good grades or keeps his or her room clean. What’s wrong with that?

    A company pays a bonus to employees who met a certain target in production or sales. What’s wrong with that?

    Of course, that’s not the Kantian way of doing things, but why are people so Kantian when it comes to the poor and so consequentialist when it comes to the rich?

    After all, no one complains that the rich (big business) don’t create employment for the sake of creating employment (and thus treating workers as an end in themselves), but to increase their own profits (thus, treating workers as a means).

  4. Mike,

    here’s a link to the article Mike refers to that works (I think)

    http://www.fastcompany.com/magazine/158/india-poverty-vaccinations

    (& btw The bribing tactic did not increase “the immunization rate from 2% to 38%” – it seems to have increased it from 18% to 38%.)

    Hi Amos,

    “So act that you use humanity, whether in your own person or in the person of any other, always at the same time as an end, never merely as a means.”

    Kant doesn’t mean we cannot ever treat people as a means – its just we shouldn’t treat them only as a means, we must at the same time treat them as ends. Of course many corporations may fail to do even that but we could not get anything done if were prohibited from making use of the skills and labour of other people and I’m sure Kant appreciated that. We can drop the word ‘bribe’, which does have connotations of corruption, and use ‘incentive’ or indeed reward. Whatever word we choose, those who we reward or bribe are still being treated as ends if they are not being lied to and are freely consenting to immunize their children. It is only if Kant views immunizing your children as a moral duty that he might disapprove of offering incentives and deterrents so people act in accordance with that duty for the wrong reasons. I know he thought choosing to innoculate oneself against smallpox was ethically problematic.

  5. s. wallerstein (ex amos)

    Jim:

    I assumed that most contemporary Kantians, if not Kant himself, see immunizing children as a moral duty and thus, immunizing one’s children because of an incentive/bribe would be a failure to cumply with one’s moral duty.

    I myself don’t believe much in the theory of moral duties. As a member of society, I have certain legal and social duties, but otherwise, the only duties I have are those I, as an obsessive compulsive neurotic personality, assign myself.

    Actually, I think that Kant was bit looney. Sometimes people are so intelligent that they become looney.

  6. Yes Amos,

    It seems pretty plausible to assume vaccination for your children is recognised as a moral duty by modern Kantians. Historical oddities about Kant are probably a bit besides the point. I suppose, strictly, Kantians wouldn’t judge the act of (not) immunizing your child as such but whether the maxim ‘behind’ such acts can be universalised. And depending on their assessment of the risk/benefits of immunization A might be willing maxim x (something about doing all you can to protect your children) whilst immunizing her child whilst B is refusing such an immunization whilst also following that maxim. B is wrong about a factual matter. If B is bribed into (what she thinks is) risking her child’s health by 1kg or lentils – unless the lentils are urgently needed to protect her children from starvation – then it seems B is to be morally condemned. If A knows not immunizing her child risks the child’s health and that isn’t enough to motivate her child to an easy access health centre she seems pretty damnable too. And the person who offers incentives to people to do what should be decided by morality presumably isn’t following a maxim Kantians will much like. But then acts seem to be describable by so many maxims and I’m not clear what the Categorical Imperative can tell us about immunization, not much I imagine.

    ‘Paternalism is a legitimate mode of government in dealing with barbarians’ offers Mike – does this not imply the Indians are barbarians? I gather immunization is compulsory in the States (though a vocal group of people get upset about this).

  7. s. wallerstein (ex amos)

    Jim:

    Thanks for the explanation.

    I was thinking that a one dollar bag of lentils isn’t much of a reward. How about a bottle of wine or couple of liters of cold beer instead?

    In Chile immunizations are not technically required, but in order to enroll a child in a state-run child-care center, they have to be vaccinated. Furthermore, any child who receives medical care in the state health system will be vaccinated, since the doctors will require it.

    Vaccination is free in the state health system, for children and for us senior citizens (flu shots).

    I’ve met hippies in Chile who live outside the system, so to speak, sell their handicrafts and do not vaccinate their children.

  8. I like this piece and I like the arguments. There is one trump card the right always plays which has been overlooked, I think. When you say 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,” I suspect the (American) conservative rejoinder would be that such policies violate the rights of individuals (parents generally trump their offspring, public aid kills individual incentives and personal responsibility, such programs invite government expansion, ad naseum, we all know the hymnal).

  9. I like this piece and I like the arguments. There is one trump card the right always plays which has been overlooked, I think. When you say 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,” I suspect the (American) conservative rejoinder would be that such policies violate the rights of individuals (parents generally trump their offspring, public aid kills individual incentives and personal responsibility, such programs invite government expansion, ad naseum, we all know the hymnal).

    And (to Wallerstein, who “was thinking that a one dollar bag of lentils isn’t much of a reward. How about a bottle of wine or couple of liters of cold beer instead?”) if children are vaccinated among the working poor of India, then a)it’s not their fathers who’ll be taking them to the clinic, and b) the last thing those children’s mothers want to see in their household is wine or beer, cold or warm.

  10. I like this piece and I like the arguments. There is one trump card the right always plays which has been overlooked, I think. When you say 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,” I suspect the (American) conservative rejoinder would be that such policies violate the rights of individuals (parents generally trump their offspring, public aid kills individual incentives and personal responsibility, such programs invite government expansion, ad naseum, we all know the hymnal).

    And (to Wallerstein, who “was thinking that a one dollar bag of lentils isn’t much of a reward. How about a bottle of wine or couple of liters of cold beer instead?”) if children are vaccinated among the working poor of India, then a) it’s not their fathers who’ll be taking them to the clinic, and b) the last thing those childrens’ mothers want to see in their household is wine or beer, cold or warm.

  11. I think focussing on the poor is a red herring here. People are suckers for small rewards even when they are not poor. It seems to be an innate deficiency in our reasoning skills.

    In the west we carefully collect reward points on our shopping even though the points may only be worth half a penny each. There is a feeling of achievement and “winning” associated with getting something apparently for nothing that outweighs the rational value of the reward. Many people will take care to collect a couple of reward points who probably wouldn’t bother to pick up a penny they dropped in the street. Dumb people are the most likely to place highly disproportionate values on these rewards and modify their purchases in a way that makes no rational sense but it works on everybody to some degree. This is why the supermarkets like these systems so much. Of course it is manipulative but then so is almost everything we are exposed to and such manipulation seems pretty open and benign compared to all the other stuff we have to put up with. At least you can take it or leave it as you see fit.

    Small incentives can be used in a much more insidious way than this. For example, it was found that a lot of office workers could be persuaded to reveal their computer passwords to people performing a bogus survey in return for a cheap chocolate bar.

    Surely the philosophical question is understanding why people are so often so bad at making choices that small or even bogus incentives are so disproportionately effective. Why are we so often “penny wise, pound foolish”? I have a sneaking suspicion that this effect is also related to a lot of political sloppy thinking. In elections, many people can be swayed by the most trivial policy or personality details if they are overhyped. It seems odd that whole elections are fought over trivial issues while big questions are ignored. Clearly this innate failing is a godsend to the manipulative but why is it so hard for the rest of us to see through it and think clearly?

    Anyway, the accusation of paternalism in the vaccination experiment seems hypocritical. When a body which has people’s best interests at heart offers incentives that is derided as “paternalism” but the offering of incentives by all sorts of other bodies (who do not necessarily have our best interests at heart) is accepted as perfectly normal. Besides that, getting kids vaccinated surely has to override such concerns. Any parent dumb enough to require manipulating into vaccinating their child deserves to be treated with some degree of paternalistic contempt.

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