Up to 50% of patients with schizophrenia prescribed antipsychotic drugs discontinue or are only partially adherent,1 thus greatly increasing the chances of relapse and hospitalisation.2 It has been proposed that offering money to patients with a psychosis in exchange for adherence to medication may be an effective means of improving clinical outcomes.3 However, a strong intuition against the idea is widely held among clinicians. A large survey of team managers of “assertive outreach” teams in England found that the vast majority would regard such a practice as unethical.4

The aim of this paper is to examine where the ethical difficulties lie. I will use the term “financial incentives for treatment adherence” (FITA) as a brief descriptive term for the practice.

SUPPORT FOR FINANCIAL INCENTIVES FOR TREATMENT ADHERENCE

Although rarely used, there is some evidence that offering direct financial incentives in exchange for medication may be effective in enhancing compliance.5 A small, uncontrolled study of five non-compliant patients suffering from a psychosis found that four patients took medication under a “money for medication” regime and improved significantly.3 Avoiding readmission was a key measure of a successful outcome.

Burns6 considers FITA in the context of “coercive” interventions in psychiatry. He argues that since FITA is an “offer” rather than a “threat”, it is a lesser form of pressure than frank coercion, such as threatening a patient with an involuntary treatment order. Claassen4 sees the practice in terms of a complex web of “reinforcements”. FITA may tip the balance, fairly, in favour of the patient taking medication:

If we think of money for medication as remuneration for the effort, pain and possible side effects that the service user has from long-term depot injections, then this is probably unfair to more compliant users. However, if we think about this as an incentive for adherence, merely tilting the balance of an individual’s informed decision-making process (much in the way as it happens with more informal gratification) towards drug adherence, person-centred incentives would not necessarily be unfair, as they (like the benefit system) merely take into account that some people need more positive reinforcement to succeed than others.4

Burns terms the transaction as a “respectful and equal exchange”. The patient can refuse the offer. Its transparency is commended, as is its “fairness”

It is hard to see how a relatively small financial inducement to take medicine to remain well, balanced against a high likelihood of relapse (and possible compulsory admission) would conflict with society’s view of fairness or justice.6

Since the sums are small and the objective of the exercise is to achieve a “commonly accepted good”, he does not consider it an “exploitation of impoverished patients”.

These arguments need unravelling. A number of morally relevant distinctions have not been clearly drawn.

THE ETHICAL ISSUES

I offer three kinds of argument that are relevant to the ethics of FITA. In addition to the ethical concerns, there are practical difficulties as well. Although I shall consider them only briefly, they might in fact be sufficient to make the intervention untenable, whatever the ethics.

The three arguments are based on: (1) incommensurable values, (2) exploitation and (3) fairness.

Incommensurable values

The idea of “incommensurable values” refers to a transaction characterised by an exchange between “goods” lying in two domains of valuation, one high and one low, or valuations that cannot be aligned along a single metric.7 Such an exchange is said to denigrate, degrade, devalue or corrupt the character of the “goods” that lies in the higher domain. Cohen8 states that “an exchange is corrupting when it ignores the differences between these spheres of valuation and forces us to value all goods in the same way”. Stark examples would be the selling of a child or of an electoral vote. The concept has been given other names—“market inalienability”—that which cannot be sold without injuring in a fundamental sense the seller, and perhaps all persons9; “commodification”8 or more simply, by Sandel as in the title of his Tanner Lectures, What money can’t buy.10

In relation to selling a baby, Radin9 describes the nature of the harms as follows:

Conceiving of any child in market rhetoric wrongs personhood. In addition, we fear, based on our assessment of current social norms, that the market value of babies would be decided in ways injurious to their personhood and to the personhood of those who buy and sell on this basis, exacerbating class, race, and gender divisions. To the extent the objection to baby-selling is not (or is not only) to the very idea of this “good” (marketed children), it stems from a fear that the nonmarket version of human beings themselves will become impossible. Conceiving of children in market rhetoric would foster an inferior conception of human flourishing, one that commodifies every personal attribute that might be valued by people in other people.

Money and healthcare are not always considered as necessarily incommensurable. As Radin and others have noted, in an imperfect world in which goods are unequally distributed, a degree of “partial commodification” is unavoidable. Restrictions of some treatments to only those who can afford them are considered by many as acceptable, although undesirable. However, FITA is not such a case.

Discussions4^–6 about FITA have not made it clear whether only patients who are non-compliant are to be offered a financial inducement, or whether all patients with a psychosis, whether they would accept or refuse medication, are to be included. For the discussion that immediately follows, I consider the measure only for those who are non-compliant.

What then are the incommensurable values in the case of FITA? FITA involves the reversal, in response to an offer of money, of a decision by a patient that he or she does not want medication. In the literature on commodification it is assumed that the parties to the exchange have the capacity to enter into the transaction—that is, that they understand the nature of what is being exchanged and the consequences of accepting or not accepting the terms of the transaction. Let us therefore assume that the patient has decision-making capacity in relation to treatment and understands the nature of the proposed transaction. By having decision-making capacity we take it that the patient understands the nature of the treatment, why it is being proposed, the consequences of having or not having the treatment, and is able to reason with that information to arrive at a decision about whether to accept the treatment or not. (While it is not stated explicitly, my reading of both Claassen4 and Burns6 is that the patients to be offered FITA have these capacities. Consent to the treatment is mentioned, which implies capacity.)

Thus FITA permits offering money to induce the patient to change what one must understand as a capable decision about medication—that is, a decision made in the light of what the patient considers is in his or her best health interests. It is a considered decision because the patient has decision-making capacity and previous attempts at persuasion about the benefits of medication have presumably been unsuccessful. The patient has weighed up these benefits and drawbacks of treatment and decided against. The harm then, is the devaluing or denigration of a decision made by the patient about what is in their best health interests. This represents in an important sense, a failure of “respect for the person”, the devaluing of a fundamental moral value, at least in our society. This would be the case for any patient, but the fact that a person with a mental disorder is subject to this denigration is especially significant. History shows how mental health services have ignored the “voices” of people with mental disorders, and how their autonomy and choices have been accorded less respect than other patients. At a time when attempts are being made to redress this balance, it is especially damaging to undermine patients’ capable, considered treatment decisions. Services today aim to ameliorate rather than reinforce the experience of social exclusion. FITA acts against this aim, promoting instead an inferior conception of personhood—of diminished agency and autonomy—of those with a mental illness.

Can a case be made for FITA where the patient lacks decision-making capacity (that is, where “respect for the person” is not at issue in the same way). There are two “capacities” that are relevant—treatment decision-making capacity and the capacity to agree to the FITA exchange. If a patient lacks both capacities, it would be difficult to claim that an exchange would be ethical. A transaction, the nature of which is not understood by one of the parties, cannot be regarded as meaningful. But perhaps a case can be made for a FITA exchange for patients who one might regard as falling into a “capacity gap”—they do not have the capacity to make treatment decisions, but they do have the capacity to enter into a FITA transaction; that is, they understand the nature, purpose and consequences of the transaction. An example would be a patient who while suffering from schizophrenia with grandiose delusions and hallucinations denies she is ill and the need for treatment. At the same time she understands that if she were to have an injection, prescribed by a doctor who (in her view mistakenly) believes she is ill, she will receive money towards payment for a weekend art workshop she is keen to attend. Here, the argument that FITA is a lesser form of pressure than frank “coercion” may carry weight.

Appelbaum and I have discussed elsewhere a hierarchy of “treatment pressures”.11 We find Wertheimer’s12 notion of “coercion” persuasive. Stated briefly, “threats” coerce while “offers” (or inducements) do not. A conditional proposal (if you do X, I will do Y; but if you don’t do X, I will not do Y, or I will do Z) is a threat if it threatens to make a person who does not accede to the proposal “worse-off”; but it is an offer if the person who does not accede is no worse-off. By worse-off, one means worse-off against a “moral base-line”—or what one is entitled to or “ought” to expect in such a situation. Thus the offer of money for taking medication is an offer since rejection by the patient leaves the patient no worse off than if the offer had never been made (if it is accepted that respect for the person in not violated when the patient lacks capacity). However, threatening the patient with involuntary treatment or instituting involuntary treatment is “coercive”—rejection of the proposal leaves the patient worse-off than if the proposal had never been made—he will be forced to have treatment. (Of course, simply because a proposal is coercive does not mean it is unethical; it can be ethical if it can be justified).

Thus FITA is an offer, not a form of coercion; but the threat of involuntary treatment, if that is the alternative, clearly is. So FITA could be justified as the “less restrictive” option. But a patient’s lack of capacity does not simply permit a clinician to administer the treatment that he or she thinks is appropriate. A commonly accepted principle, set out, for example, in the Mental Capacity Act 2005 in England and Wales, is that treatment should only be administered in such cases if it is in the patient’s “best interests”. Essentially, this requires a consideration of what treatment the patient might have chosen in their current predicament if they had had the capacity to do so. So regard is paid to past expressions of preference by the patient (for example, in an “advance statement”, or comments to others) or what is known of the patient’s values or life-style choices. Also to be considered is how the patient, having recovered capacity, would feel about the FITA exchange. The involvement of a substitute decision maker or advocate could be helpful in ensuring best interests assessment is conducted appropriately.

If this approach is accepted, one may conclude that FITA could be justified for patients falling within the “capacity gap”, where treatment is in their best interests. Consideration would also have to be given as to whether being given money would serve the patient’s best interests. While FITA is not a desirable course of action, it may be preferable to coercion, depending on the patient and the circumstances. The exchange should end when the patient recovers decision-making capacity for the reasons mentioned earlier in relation to patients retaining capacity—FITA is not acceptable when a patient has treatment decision-making capacity. (Of course, a practical problem may emerge at this juncture—will the patient be tempted to refuse medication if no longer in receipt of the inducement?)

Some further points concerning “commodification” are relevant. Writers on the subject agree the arguments are difficult. Cohen8 has shown how tricky it is to define the boundaries of domains of goods that have radically different spheres of valuation. For example, one might divide all goods into “use” goods which have only instrumental value (such as money) and “non-use” goods which have “intrinsic” value (such as aspects of human flourishing), but exceptions can be found. Cohen argues that in thinking about commodification an element besides the “nature of the goods” should be also be considered—the “nature of the transaction”. Why is baby-selling considered wrong, while adopting a child, a procedure in which some small sums of money are exchanged, is not? Cohen makes a distinction between transactions that express “value equilibrium” and those that do not. In the former, each party to the transaction receives a thing of equal value. For example, the money paid for a car is equal to the value of the car. There is no “value remainder”. With gifts there is no assumption of value equilibrium—a gift is not equivalent in value to a friendship. Such non value equilibrium exchanges characterise exchanges between recognised incommensurable value domains. Paying a finder’s fee in an adoption exchange recognises that the money is not equivalent to the value of the child. There is a “value remainder”, or uncompensated value.

In the case of FITA it is not always clear whether what is being proposed is a “value equilibrium” transaction or not. This has not been addressed directly. However, when one of the benefits of FITA is said to be a reduction in hospitalisation costs6 such might indeed be the case. If FITA is intended to express a value equilibrium transaction, the incommensurable values argument against the practice is very strong. In such a case there are also other issues that need to be addressed. Does the transaction entail a some kind of contract imposing duties and obligations. Would there be legal remedies if the patient were to develop serious adverse effects and claim that he or she would not have taken the medication if it were not for the money? Perhaps claims for different levels of payment could be made for different degrees of expected effectiveness or side-effects.

Sandel10 points to another difficulty that characterises commodification arguments:

The argument … has to be made in a different way, case by case. It must be shown how, in each case, market valuation and exchange degrades or corrupts important values or ends that non-market practices may embody.

Thus I have restricted myself to FITA in relation to patients with severe mental illness, and have not considered, for example, the use of contingency management in the addictions,13 the payment of research subjects or the large literature on selling body parts. Possible harms to different aspects of human flourishing, identity, personhood or social cohesion may come into play in relation to each type of payment, requiring its own separate ethical analysis.

Sandel goes on to say:

Since the argument from corruption points not to consent but to the moral worth of particular human goods, the question arises how the case for these goods can be established … Arguments of this kind are subject to two familiar objections: if we derive the fitting or proper way of regarding goods from the social meanings that prevail in a given society at a given time, we run the risk of lapsing into conventionalism. … If, however, we derive the fitting or proper way of regarding goods from some notion of the essential nature of the practices in question, we run the risk of essentialism—the idea that the purposes and ends of social practices are fixed by nature.10

Perhaps it is for these reasons that opinions about commodification are so divergent. In an increasingly materialist society where the market continually encroaches into new domains, it can appear that commodification, for example, in the sale of body parts or in surrogate pregnancies, has the potential to expand inexorably.

Exploitation

A distinction can be made between “coercion” and “exploitation”.11 As noted earlier, threats presented as conditional proposals are coercive if they aim to make the recipient act according to the proposer’s will and would make the recipient worse-off according to a moral baseline. However, in cases of exploitation the threat does not issue from the person who is making the proposal. The threat against which the proposal is made is a “background” threat.14 An example will make this clearer. Suppose it is snowing heavily and A must dig out his driveway to keep an important business appointment. He goes to B’s hardware store to buy a shovel. The normal price of a shovel is £10, but B, seeing that A is in desperate need, offers to sell it to him for £20. B is not responsible for the background threat—the snowstorm. If A decides not to buy the shovel, he is not worse off then he was before B made the offer; that is, he has no shovel and can’t get to his appointment. In fact, B’s proposal is a type of “offer”, not a “threat”. Most would agree that A does not have an entitlement to buy the shovel for £10. A’s possibilities are expanded as a result of this offer, not diminished. However, most would see B’s behaviour as morally reprehensible. So exploitation involves a problematic offer. The wrong lies in someone taking unfair advantage of another.15 It is noteworthy that exploitation can be mutually advantageous12 (yet unfair)—in this case if A agrees to buy the shovel, he gets to his appointment, while B makes a tidy profit.

A strong argument can be mounted that FITA, if accepted by the patient, relies heavily on exploitation. Patients with serious mental illness are often severely disadvantaged, perhaps largely as a result of their illness. Unemployment rates are high, and social exclusion is common. While the sums being offered for each dose of a depot antipsychotic are small from the clinician’s perspective—£5 to £15 has been mentioned—from the patient’s they may be substantial. Fixing a sum which is non-exploitative may be problematic. A very small amount might be appropriate—perhaps £1. There then would be no question of a transaction expressing “value equilibrium”. But how many patients would agree to the transaction?

Taking medication may be advantageous for the patient in terms of their clinical condition, but that does not make the transaction non-exploitative. As noted above, exploitation can be mutually advantageous. But what is the advantage for the clinician? Seeing one’s patient improve is undoubtedly rewarding. But there may be other motives. In many mental health services there are enormous pressures on inpatient beds. Admissions can be difficult to arrange. Large savings on inpatient costs have been made by a huge reduction in the number of psychiatric beds—from 152 000 in 1954 to 29 800 in 2006 in the UK.16 Preventing admissions saves the health services money. In FITA, the clinician may, in effect, be acting as an agent of the health service in reducing costs (and may be rewarded for doing so by management).

Perhaps this is too cynical. But let us imagine another set of circumstances. Health services offer £5–£15 for fortnightly injections which would render a patient with schizophrenia suitable for a very expensive implant procedure, which would then be followed by long-term costly maintenance treatment. This treatment holds the promise of substantially improving a patient’s quality of life. Would FITA be offered in these circumstances?

Fairness

In this section I consider a different form of “fairness” to that in exploitation. It deals with distributive justice in the population of patients.

I presume it is not proposed that all patients who require a particular treatment—for example, all those suffering from schizophrenia who are prescribed a depot antipsychotic—should receive a financial inducement. At a purely practical level, under such as scheme, the costs would become large. Wherever the dividing line is to be drawn, the issue of fairness would arise in justifying why some patients are to be paid while others are not.

The question of fairness is even more strongly at issue under a scheme where only those unlikely to comply with medication would be offered FITA. Why should patients who decide to take medication be penalised for a prudent choice? Perhaps many patients, content to take medication, would be tempted to say they would not, in order to receive the inducement. Fairness would require that all teams within a service should operate the same policy; indeed within the NHS the policy would need to be national. Otherwise patients who move home might refuse to transfer to a service nearer geographically, and thus better able to meet a range of needs, that did not offer FITA.

Psychiatric practice has become increasingly politicised. Fears that community care entails an increased risk of violence by the mentally ill fuels policies that aim to ensure patients do not disengage from treatment. One can envisage FITA being offered preferentially to those deemed to be a risk to others.

SOME OTHER PROBLEMS

Shaw,17 like Claassen,4 touches on the problems I have dealt with under the fairness argument above. She also goes on to question whether it would ever be possible to screen patients to determine who would be non-adherent to medication and asks whether by introducing payment, voluntary adherence will disappear. The possibility arises that the offer of payment may make patients who have limited confidence in a treatment more doubtful still—why should one be paid to do something which is in one’s best interests? The money may be seen as a compensation for expected adverse effects. Some of Claassen’s respondents were concerned at possible effects on the therapeutic relationship. FITA introduces a new element. Perhaps it would lead to less emphasis in engaging the patient in treatment by using traditional interpersonal and psychotherapeutic skills. Some patients may fail to disclose or minimise symptoms or conditions which may be contraindications to a treatment for fear that it will not be prescribed. Discontinuation of medication, if that were to be indicated, might be resisted by the patient. There is also the question of when and how FITA should be terminated—if ever. It is hoped that following stabilisation on medication, the patient might come to recognise its value.

Shaw also suggests that there are problems in “policing” the agreement: how will the clinician know that the patient is taking the medication? A treatment delivered by an intramuscular injection is relatively straightforward. However, adherence to oral medication is much more difficult to ascertain, and may involve blood or urine samples, the latter perhaps needing to be witnessed. Intramuscular preparations may not be available for the drug of choice; an injectable drug may thus constitute inferior treatment.

CONCLUSIONS

An outline of the ethics of financial incentives for treatment adherence for psychosis suggests that, at most, a case may be made for its appropriateness for a narrowly drawn group of patients. To date, the practice is probably rare in mental health care, but is gaining support. A randomised controlled trial is planned in the UK.

The proposal that FITA involves a “respectful” transaction without exploitation4 6 does not withstand scrutiny. I have presented three ethical concerns. An argument from “incommensurable” values holds that the two goods—money and a patient’s considered decision about what is in their health interests—cannot be valued on the same metric; being treated as if they could, denigrates the higher valued good—a form of respect for the person. While this would apply to all illnesses, it has special significance in mental illness. However, the argument from incommensurable values may allow financial inducement for a group of patients who do not have treatment decision-making capacity but who do have the capacity to engage in a FITA transaction; but only if such an exchange is in their “best interests”. This may represent a less “coercive” intervention than the threat of involuntary treatment. An argument based on “exploitation”, while not denying that advantage may accrue to the patient, may restrict eligibility even further. When one adds considerations of fairness and problems of a practical kind, the appropriateness of FITA is further restricted.

Thus, I believe the practice is unlikely to achieve a significant place in mental health care. Views about the practice from patients who might become the subjects of FITA would be of considerable interest.