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Plans to give drug users shopping vouchers to attend treatment programmes and stay clean have been unveiled by NICE. Joanne Shaw believes that payment creates perverse incentives, whereas Tom Burns says rewarding patients for cooperation is consistent with good medical practice
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 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.
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.2 3 4 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 are they entirely free. Negotiation is a constant reality in mental health care. As for life in general, all relationships imply a constraint, whether imposed by respect, love, family duty, or other.
Rewarding patients to cooperate is not new. In a study of over 1000 public mental health patients in the United States, half reported an offer of either coercion (compulsory admission or a jail sentence) or a reward (housing, financial benefits, release from jail) if they adhered to psychiatric treatment.5 Our preliminary work in the United Kingdom found similar rates, although patterns may differ.6
Most mental health practitioners reward patients for “healthy” behaviour. Behaviour therapies are based on explicit and consistent rewards; positive therapeutic relationships predict outcomes from dynamic psychotherapies7 to community care of patients with schizophrenia;8 all services emphasise “engagement” and staff prize their skills in achieving it. We are so routinely involved in rewarding and shaping behaviour that we hardly register it.
Money for taking drugs has been explored in randomised controlled trials in physical disorders with good results and little controversy9 and in some non-randomised mental health studies.10 11 People who criticise money for medicines emphasise the “exploitation of impoverished patients” and worries about how patients would spend the money. Defending the policy is not, however, a defence of an unfettered free market—we must apply the same ethical sensitivity here as with any financial transaction. The sums involved in the studies were modest—far removed from the exploitation involved in the sale of organs in the developing world. Neither is the money offered for an improper purpose (such as in prostitution), where it would be unethical, irrespective of the sum involved. It is a modest sum offered for a commonly accepted good—namely, helping a patient stay well. Whether a payment represents a just reward or immoral exploitation depends on the circumstances not the transaction.
All of us who are employed accept payment to shape and reward our behaviour and we spend that money as wisely or unwisely as we choose. Why should voluntary psychiatric patients have to spend their money any more wisely than we do?
From the Macarthur group's sustained research into coercion, Bonnie and Monahan argue for adopting the language of contract.12 A contract framework permits a unifying examination of the ethics of leverage, coercion, or payment for taking medicines. Whether an offer is coercion or reward depends on the patient's baseline. If a homeless patient is offered an apartment linked to treatment it is a reward, if threatened with eviction if he or she doesn't take treatment it is coercion. Few patients offered mandatory mental health care instead of prison consider it coercion.5
The Macarthur studies found that a sense of fairness and “being heard” (procedural justice) can matter almost as much as treatment pressures. A sense of fairness and respect (central to most human concepts of justice) needs to be included in any judgment of what is acceptable in treatments. It is hard to see how a relatively small financial inducement to take medicine to remain well, balanced against a high likelihood of relapse (and possible compulsory admission) would conflict with society's view of fairness or justice. Its transparency is surely one of its ethical strengths. It is absolutely clear what is being offered and why; there is no hypocrisy, no mystique. I tell you what I want you to do and offer you payment to do it. You can refuse for any reason you wish and that's that.
Far from being unethical and unacceptable money for medication is a refreshingly honest acknowledgement of the different perspectives of the two parties involved. Rather than some sophisticated technique to manipulate patients to do what we want them to do it provides a model of respectful and equal exchange. Claassen's initiative should be applauded, extended, and further researched.
Competing interests: None declared.
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