The Supreme Court spent a significant share of last week’s oral arguments on the Affordable Care Act debating the role of money in public health. Can the government rightly fine people for not buying health-care coverage? And what happens if such rebels face no penalty? Would we all, as a result, wind up less healthy?
This line of thinking — the fine as a stick used to punish people who won’t get health care — isn’t the only potential contribution of money on public well being. Health researchers and behavioral economists are increasingly pondering the reverse: cash as carrot. Would people be healthier if we paid them to be? Would they stop smoking, or lose weight, or turn up for an HIV test if we dangled cold, hard currency?
“Before you go out and roll out an extensive program of paying people to do something, you want to make sure that it’s going to be effective, you want to make sure it’s going to be cost-effective, you want to make sure it’s not going to wind up producing unexpected, unanticipated adverse consequences,” said Alex John London, director of the Center for Ethics and Policy at Carnegie Mellon University. “It’s important that we do research on these programs to determine whether they live up to the high expectations that some people have for them.”
There is one catch, however, in executing these important studies: cash, deployed in a research context, has long raised ethical red flags. Sure, researchers can pay subjects to validate their parking or compensate them for taking time off from work to participate in health studies. But cash payments to make specific decisions in research can cross the line into coercion, enticing subjects to pursue a treatment or a medication they might not otherwise have chosen. In the language of research ethics committees, money may undermine the autonomy of people to make their own decisions.
London points out that in this conversation, the research community has never really distinguished between money to participate in studies, and money as the intervention itself. This is because we’ve only recently begun talking about the potential curative powers of cash. London has written in PLoS Medicine, along with David A. Borasky Jr. and Anant Bhan, that it’s time to reconsider the ethics of money in health research.
The three are members of the Ethics Working Group of the HIV Prevention Trials Network, which is testing cash incentives in a pair of ongoing trials. One study in the U.S. is looking at the effectiveness of financial incentives to expand HIV testing and link patients to care. The other, in South Africa, is offering cash transfers to young women in exchange for attending school (in the hopes that may decrease their HIV risk).
In both of these cases, the cash isn’t luring people to make poor decisions in the interest of science. It’s motivating them to achieve goals from which they directly benefit — and which they might already desire. A similar scenario applies to a program offering you money to lose those last 10 pounds. You want to lose that weight. You’ve been trying to for some time now.
“Part of the goal of the incentive there is to get them over this motivational hump,” London said. And what’s unethical about that?
The authors acknowledge there are still potential unethical uses of cash in health research. They do want to open a dialogue about how the role of money in science may be more nuanced than current ethical guidelines allow for. This is the first step in the much broader conversation about implementing this idea in the real world (if research bears out that it works).
There are other ethical questions involved in rolling out such cash incentives as health policy (again, assuming they’re effective). If your employer offers you a nice check to quit smoking, is that fair to your coworker who’s never touched a cigarette? And what about the equity issues involving whole communities that can’t afford to encourage better health through cash payments? (As a related note, London suggests it might not be ethical to research cash payments in communities that can’t realistically sustain such an intervention in the real world.)
We may get to these ethical questions in time. But first, we need to figure out if that’s a conversation worth having.
“I personally don’t know whether in 10 years we’re going to be paying people to do a lot of things, or whether we’re going to say, ‘Well, that turned out not to be a good way to go. What’s next?’” London said. “I don’t know. But the only way to find out is to study some of these things carefully.”