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Cardiovascular Perspectives

Patients as Mercenaries?

The Ethics of Using Financial Incentives in the War on Unhealthy Behaviors

Scott D. Halpern, MD, PhD, M. Bioethics; Kristin M. Madison, JD, PhD and Kevin G. Volpp, MD, PhD

From the Center for Health Incentives, Leonard Davis Institute of Health Economics (S.D.H., K.M.M., K.G.V.), the Department of Medicine (S.D.H., K.G.V.), the Center for Bioethics (S.D.H.), the Center for Clinical Epidemiology and Biostatistics (S.D.H.), the School of Law (K.M.M.), the VA Center for Health Equity and Promotion (K.G.V.), and the Department of Health Care Management, the Wharton School (K.G.V.), University of Pennsylvania, Philadelphia, Pa.

Correspondence to Scott D. Halpern, MD, PhD, Center for Clinical Epidemiology and Biostatistics, 724 Blockley Hall, 423 Guardian Dr, Philadelphia, PA 19104-6021. E-mail scott.halpern@uphs.upenn.edu

Key Words: obesity • risk factors • smoking • ethics • incentives

An extract of the first 250 words of the full text is provided, because this article has no abstract.

	Introduction

 
Consider the following paradox: Few people would balk if researchers offered smokers $1000 to participate in a year-long randomized trial of a smoking cessation intervention, yet many would find it distasteful for a large employer to pay its smoking employees an extra $1000 if they remained smoke-free for 1 year.

Editorial see p 402

Such discrepant judgments are understandable from the perspective of classical economics. Research participants merit compensation for the risks and opportunity costs they endure in the service of public health, whereas individuals should need no reward for promoting their own well being. However, contrary to traditional theories of rationality, people frequently fail to make health-promoting choices, particularly when such choices require short-term sacrifices to foster long-term goals.^1,2 Thus, corporate and government health plan leaders are increasingly applying extrinsic motivations such as financial incentives and other programs to augment health—particularly cardiovascular health—while hopefully increasing productivity and restraining costs.^3,4

Early evidence suggests that financial incentives can effectively promote the cardioprotective behaviors of smoking cessation,^5,6 weight loss,^7,8 and cholesterol reduction.⁹ Incentives are also currently being studied as a means of promoting warfarin adherence.¹⁰ Although the results of these early studies are promising, further research is needed to determine which incentive structures and amounts are optimal, assess the ability of incentives to produce sustained behavior changes, and evaluate the cost-effectiveness of implementing incentive programs.

Ethical dimensions of the incentives themselves are also in need of further analysis. For example, some have charged that financial incentive programs are coercive, inequitable, and inconsistent . . . [Full Text of this Article]

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