Drug addicts will be given shopping vouchers if they agree to be treated and stay clean, unveiled by the UK’s National Institute for Health and Clinical Excellence last month. This move opened up an interesting ethics debate which was explored in a recent issue of the BMJ: should patients be paid for taking their medication? Apart from drug addicts, such a scheme might also be useful in persuading people with mental illness to follow doctor’s orders.
Representing the affirmative was psychiatrist Tom Burns, of Warneford Hospital. How can it be considered ethical to lock a psychotic patient up and force him to take medicines, yet unethical to pay him to take them, he asks. There is some evidence that payment works, he writes. One US survey found that half of all mental patients had been offered some form of reward or coercion to cooperate in their treatment. In fact, payment is an acknowledgment of fairness and respect.
Rerpesenting the negative was Joanne Shaw, a UK health bureaucrat. Non- adherence to drug regimes can be very costly, she acknowledges. Transplant patients who neglect to take their anti-rejection drugs lose their organs or their lives, for instance. However, payment for adherence creates perverse incentives because even people who do not need it would ask for payment. “After all, why should patients agree to take medicines for nothing if they can be paid?” In the end, everyone might be pauid, at an enormous cost. Furthermore, it raises serious questions about informed consent. Payment sends a signal that patients are being asked to do something which is not really in their own interest.
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