Patients as Mercenaries?

Consider the following paradox: few people would balk if researchers offered smokers $1,000 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 $1,000 if they remained smoke-free for one year. 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 with shared social values.11 Others have even suggested that implementing incentive programs serves to punish patients for their illnesses.12 In this essay, we outline the rationale for incentive programs to promote cardiovascular health, identify the ethical arguments that have been used to challenge such programs, and assess the merits of these arguments.