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HEAD TO HEAD: Jennie Popay Should disadvantaged people be paid to take care of their health? No BMJ 2008; 337: a594 [Full text]

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We need to understand the mechanisms underlying incentives better.

Richard E Ashcroft, Theresa Marteau and Adam Oliver   (23 July 2008)

Conditionality and family payments – a cautionary tale for policy makers

Patricia J Lucas   (30 July 2008)

We need to understand the mechanisms underlying incentives better. 23 July 2008
Richard E Ashcroft, Professor of Bioethics Queen Mary, University of London; School of Law; Mile End Road; London E1 4NS, Theresa Marteau and Adam Oliver Send response to journal: Re: We need to understand the mechanisms underlying incentives better.	Dear Editor Cookson and Popay make some important points about the merits and problems of using cash incentives to change health behaviour in disadvantaged populations.(1), (2) However to decide on the desirability of these sorts of schemes, far greater ethical clarity is needed, alongside empirical evidence to inform this ethical evaluation. Cookson makes three moral arguments, and one prudential argument, for cash incentives. First, cash incentives provide an inducement to recipients to change their behaviour in the direction of lessening harm to third parties. He justifies this with an appeal to Mill’s harm principle. This is a bit strange: Mill would have had difficulty recognising indirect harms to third parties via resource allocation impacts as the sort of harm that would meet the threshold for state intervention. But if we accept this reading of Mill, we could go further and consider direct coercion, for instance, through criminal sanctions. We would then need an argument about why paying people is the approach to take rather than direct coercion. This debate is made still more complicated by the view held by many that incentives reward people for doing what they ought only in response to the inducement, rather than out of personal responsibility or morality. Second, cash incentives create a (heightened) obligation on recipients to change their behaviour in ways that minimise the burden on fellow citizens (by implication, those paying for the incentive and carrying the burden of the externalities of the adverse health behaviours). This is an interesting argument about solidarity, worth exploring. Yet on the face of it, benefit schemes which imply incurring an obligation to the donors has a history of producing resentment in welfare recipients. Help with strings attached might well be considering exploitative and stigmatising. If so, this alteration in the moral relationship between donor and recipient might undermine the effectiveness of the scheme. This requires empirical investigation. Third, and implicitly, Cookson holds that the paternalistic motive for incentivising behaviour change is not acceptable. This is somewhat surprising, given that the trend in public health and public health ethics seems to be in the direction of Sunstein and Thaler’s “libertarian paternalism” (3). By focussing so much on third party costs, he overlooks the important debate about the way autonomous choices may be shaped using paternalistic techniques, and the ways this may be justifiable. Finally, he has a prudential argument: this sort of scheme works, often, and produces an excess of good over harm. This is important, and we need more evidence to understand how and why these schemes work, when they do. Popay’s arguments against Cookson’s position contain many suggestions about the mechanisms involved in behaviour change under incentives, although the experimental evidence needed to test these claims is so far rudimentary in comparison with the wealth of outcome evidence testing raw effectiveness. Her arguments about the equity impact on different communities are important – both she and Cookson agree that these schemes have greater impact on the disadvantaged, but disagree both about why and about whether this is necessarily a good thing. Again, she may well be right about the dual stigma of being overweight and being paid to lose weight (for instance), but further evidence is needed to establish this. All of this suggests we are at the beginning of a wide public debate on the merits, moral and otherwise, of these schemes. We are beginning a 5 year Wellcome Trust funded programme of experimental work in psychology and economics, and conceptual work in philosophy and ethics, which will provide some of the answers to the questions Cookson and Popay have so helpfully framed.(4) Reference. (1) Cookson R. Should disadvantaged people be paid to take care of their health? Yes. BMJ 2008; 337: 140 (2) Popay J. Should disadvantaged people be paid to take care of their health? No. BMJ 2008; 337: 141 (3) Thaler RH, Sunstein CR. Nudge: Improving Decisions About Health, Wealth and Happiness. New Haven: Yale University Press, 2008 (4) http://www.kcl.ac.uk/schools/biohealth/research/csincentiveshealth/ (accessed 23-07-2008). Competing interests: We recently received funding from the Wellcome Trust for a Strategic Award in Biomedical Ethics to carry out ethical, economic and psychological studies on the use of personal incentives to promote public health.
Conditionality and family payments – a cautionary tale for policy makers 30 July 2008
Patricia J Lucas, Lecturer in Early Childhood Studies School for Policy Studies, University of Bristol, UK, BS8 1TZ Send response to journal: Re: Conditionality and family payments – a cautionary tale for policy makers	I have followed the discussion on the debate on conditional payments for health with interest (1,2,3). My particular interest is in the impact of social policy changes on the health and wellbeing of children. Few would argue that more money and greater uptake of those public health interventions known to be effective won’t benefit children. There is rich and plentiful observational evidence that suggests that children in wealthier families are healthier and have improved life chances. However, a cautious approach should be taken to adopting conditional payments as a means to increase family wealth and child wellbeing. Ashcroft et al (4) rightly call for empirical as well as moral reasoning to be considered when judging the merits of this approach. There have indeed been experiments (5), albeit that they are tied to meeting working conditions rather than health behaviours. Before another experiment, we need to pull together what we know in a context dependent way. Firstly we need to ask, will it work here? We are used to considering whether evidence from wealthier countries will translate to low and middle income countries or whether it will transfer between different high income countries. In this case we are asked to consider whether evidence will transfer from poor to rich. To understand the impact of wealth on health we have to consider that once basic needs are met the relationship is not direct. In high income countries absolute poverty is rare, but health inequalities still exist (6). In this context we need to consider the likely impact of conditionality itself on the social and financial circumstances of the families targeted. In experimental studies in wealthier countries the impact for children of such conditional payments has been poor (5). This may have been attributable either to the stress of meeting the work conditions, or to the low value of additional funds. Either of these explanations should lead us to at least question the expansion of conditional schemes as a means of addressing inequalities. Secondly, we need to think carefully about pinning benefits for children to parental behaviour. We spend considerable energy trying to ensure that welfare systems target their beneficiaries. Under a conditional payments system, those children at greatest risk may be further disadvantaged. (1) McColl K., New York’s road to health. BMJ 2008;337:a673 (2) Cookson R. Should disadvantaged people be paid to take care of their health? Yes. BMJ 2008; 337: 140 (3) Popay J. Should disadvantaged people be paid to take care of their health? No. BMJ 2008; 337: 141 (4) Ashcroft RE, Marteau T and Oliver A We need to understand the mechanisms underlying incentives better (5) Lucas P, McIntosh K, Petticrew M, Roberts HM, Shiell A. Financial benefits for child health and well-being in low income or socially disadvantaged families in developed world countries. Cochrane Database of Systematic Reviews 2008, Issue 2. Art (6) Ramsay, S E, Morris, R W, Lennon, L T, Wannamethee, S G, Whincup, P H (2008). Are social inequalities in mortality in Britain narrowing? Time trends from 1978 to 2005 in a population-based study of older men. J. Epidemiol. Community Health 62: 75-80 Competing interests: None declared