Head to head

Is it acceptable for people to be paid to adhere to medication?

YES. How can it be considered perfectly ethical to lock up a patient with psychosis and force them to take drugs against their wishes and yet be “unacceptable” and “unethical”¹ to offer them money to take the same drugs to stay well? Claassen and colleagues offered five assertive outreach patients, with whom they had failed to establish effective maintenance medication, £5-£15 (€7.5-€22; $10-$30) for each injection of depot antipsychotic.¹ Four accepted the offer and have done well; three have stayed out of hospital for two years of follow-up; and one improved so much he demanded a pay rise. It doesn't need a health economist to calculate that two years of such payment costs less than a day or two in hospital.

Rewards and coercion already exist

The intense opposition generated by Claassen's report of “money for medicines” should make us think about how we debate the moral problems of modern mental health care. It shows how inadequate our current language (locked into oversimplified polarities of “autonomy” and “coercion”) is for this task, and it may have flushed out some overly paternalistic attitudes.

There is a body of research investigating patients' experiences of coercion, not just their legal status.²⁴ More than half of “voluntary” patients don't feel voluntary, and many “involuntary” patients do not feel particularly coerced. Patients acknowledge that our interactions involve a complex trade-off between what they want, what their families want, and what doctors want. Choices are constrained–patients may not be legally compelled to go along with us, but neither …