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Effectiveness of financial incentives to improve adherence to maintenance treatment with antipsychotics: cluster randomised controlled trial

BMJ 2013; 347 doi: (Published 07 October 2013) Cite this as: BMJ 2013;347:f5847

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Re: Effectiveness of financial incentives to improve adherence to maintenance treatment with antipsychotics: cluster randomised controlled trial

A substantial proportion of patients with a psychotic illness do not take prescribed medication (although, if the numbers in this study by Priebe et al (1) are to believed, much fewer than other research would suggest). Interventions to improve matters are most welcome. However, offering financial incentives to patients to take antipsychotic medication presents serious ethical problems, the most important of which, I think, is one that might be termed ‘incommensurable values’ (2) or ‘commodification’, or, more simply, ‘what money can’t buy’ (3).

Selling a baby, or an electoral vote, are classic examples. The idea of ‘incommensurable values’ refers to a transaction that involves an exchange between ‘goods’ lying in two different spheres of valuation, one high and one low. Aligning their evaluation along a single metric, one that characterises the lower value (for example, money), denigrates, degrades, devalues or corrupts the character of the ‘goods’ that lie in the higher domain (for example, a baby). Such an exchange fosters an inferior conception of human flourishing or of personhood.

The financial incentive in the study of Priebe et al involves offering money to induce a reluctant patient to change their mind about medication. So where is the harm? The patient has apparently made a decision in the light of what in their view is considered to be in their best interests. Previous attempts at persuasion about the benefits of medication have presumably failed. The patient, having weighed up these benefits and drawbacks of the medication, has decided against. The harm lies in 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’, for their agency or self-government, fundamental values, at least in our society. There may also be a denigration of the value of the treatment - that it becomes a commodity rather than serving a higher value related to human flourishing.

Some may respond to this argument by noting that in our market-dominated society we are constantly, indeed increasingly, being influenced to act in particular ways by financial incentives – for example, through tax breaks or through ‘special offers’ (4). This may be so, but in the context of mental health services, special caution is necessary. History shows how mental health services, together with nearly all institutions in society, have ignored the voices of people with mental disorders, and how their autonomy or ‘competence’ have been accorded less respect than others, including other patients. Surely psychiatric treatments should aim at strengthening patients’ conceptions of their personhood and agency, and aim to ameliorate rather than reinforce the experience of social exclusion. The danger of offering financial incentives lies here. A new set of dynamics could well come into play that might amplify the scope of the harms. When it becomes known that payment is offered when one says ‘no’ to medication, why would one say ‘yes’- especially when in straitened circumstances as is unfortunately often the case among patients with psychosis?

There are a number of further considerations to be taken into account in relation to the argument I have outlined. What about the situation where the patient lacks the capacity to make treatment decisions? I have discussed this elsewhere, as well as other ethical obstacles involving the potential for ‘exploitation’ and ‘unfairness’ (2). There is, of course, a range of practical issues that has been raised by others (see, for example, Shaw(5)).

1. Priebe S, Yeeles K, Bremner S, Lauber C, Eldridge S, Ashby D, David AS, O'Connell N, Forrest A, Burns T. Effectiveness of financial incentives to improve adherence to maintenance treatment with antipsychotics: cluster randomised controlled trial. BMJ. 2013;347:f5847.
2. Szmukler G. Financial incentives for patients in the treatment of psychosis. J Med Ethics. 2009;35:224-228.
3. Sandel MJ. What money can't buy: the moral limits of markets. London: Penguin; 2012
4. Dunn M, Maughan D, Hope T, Canvin K, Rugkasa J, Sinclair J, Burns T. Threats and offers in community mental healthcare. J Med Ethics. 2012;38:204-209.
5. Shaw J. Is it acceptable for people to be paid to adhere to medication: No. Br Med J. 2007;335:233.

Competing interests: No competing interests

26 October 2013
George Szmukler
Professor of Psychiatry and Society
Institute of Psychiatry, King's College London
de Crespigny Park, London SE5 8AF