The study illustrates what issues are likely to be raised when financial incentives to achieve medication adherence in non-adherent patients with psychotic disorders are discussed. Each stakeholder group covered most of the same discussion threads, albeit with different emphasis and arguments, but there were no clear differences between groups. The concerns expressed in the 11 themes need to be addressed whenever a wider application of the practice is considered. The relevance of these themes is twofold. First, they arise prior to any consideration of the evidence of effectiveness of either treatment or incentives for treatment. Therefore, they shape the perception and argument around the topic of incentives in an important way. They are also broadly consistent with academic arguments about incentives. One methodological question arising in our study was whether we were ‘promoting’ the use of incentives, or whether our prior attitudes to antipsychotic drug therapy were relevant in framing and analysing the issues under investigation. Obviously, a degree of reflexivity is necessary here. But the very concern raised about whether we are in some way biased or whether our framing prejudged the discussion is itself something that was discussed in the groups, and underscores the way in which prior moral attitudes frame the debate in ways that seem rather insensitive to evidence, even where evidence should be relevant.
Strengths of the study are that very different stakeholder groups were included, saturation was reached, and the results appear plausible as a criterion of validity. Weaknesses are the general limitations of focus group methodology and the fact that very few participants had any experience with using financial incentives, so that most concerns had a speculative nature.
The debate in the groups raised wider issues and specific concerns, which to some extent reflect a suspicion that offering financial incentives might not only be a desperate attempt by clinicians to help patients in whom all other means have failed, but also that there are improper motives and even a government agenda behind it. One can only speculate whether this is influenced by the public nature of the NHS, the way that the NHS has been run using top-down initiatives, and the general politicising of health service issues in the UK. Aside from health system-specific issues, it was not clear how far participants attitudes were driven primarily by concern for the individual patient's well-being and respect for their autonomy, and how far they were shaped by a concern for social justice and equity in ways better captured by a public health model of the use of incentives.14
Having said that, most of the concerns identified relate to concerns on individual behaviours and attitudes, and for between-patient considerations of fairness.
Whether offering financial incentives is an acceptable option or not is an issue for an ethical debate, and the findings of this study can inform such a debate. Since most of the ethical arguments raised seem to relate most to a clinical frame of reference concerned with the individual patient, a normative model drawn from medical ethics may best capture the nature of these concerns. A standard framework for describing such concerns is that of Beauchamp and Childress,15
who suggested four ethical principles guiding the consideration of healthcare interventions: autonomy, beneficence, non-maleficence and justice.
Each of these principles has been addressed by the results. The autonomy of the patient might be affected through a coercive effect of financial incentives with unclear responsibilities for potentially harmful medication effects, especially in the long term. While it may be argued that the model of coercion implied in the respondents' discussions was inchoate and arguably quite imperfect from a philosophical point of view, notions of coercion were frequently invoked and appeared highly salient.
Beneficence overlaps with the issue of effectiveness, but is also linked to the frequently discussed question of whether offering financial incentives is in the interest of the individual patient or the public at large. Ethically, only the former might be seen as a justification to implement the practice in a voluntary treatment setting. In addition, capacity to make the decision and provide informed consent would be required.
Several aspects concerned non-maleficence, referring to potential harm. This may affect patients on such a scheme through the withholding of time-consuming alternative methods, more complicated relationships with their clinicians, more negative attitudes towards medication, or the harmful use of the money for drugs. It may also affect other patients who might become non-adherent to be eligible for financial incentives.
The issue of justice was directly mentioned as some participants found it unfair that some patients received money to take medication and others did not. Such a position may be challenged by arguing that resources for health interventions need to be distributed following the needs of the individual concerned.
The four-principles approach is only one approach to thinking about the ethics of medical treatment, and of incentives, but it has the virtues of simplicity and clarity. Although frequently criticised for being simplistic, it does help make sense of the ‘ordinary ethics’ recorded in the focus group discussions.16
Relevant stakeholder groups expressed concerns about using financial incentives to achieve medication adherence in patients with psychotic disorders. If the practice is to be used more widely despite these concerns, financial incentives should be regarded as an option for a clinician and patient in an individual case, rather than be implemented following a general guideline. The study has clearly shown why offering financial incentives to achieve medication adherence will remain a controversial subject. While the ethical decision may depend on various factors, including the central question as to whose interest is being served, some of the concerns can be addressed by precise policies with appropriate safeguards, and others might be clarified in further research. Our analysis here is not intended to be a full ethical analysis of the issues, but rather to identify which issues are salient in stakeholders' appraisals of the use of incentives to promote medication adherence, and to examine how these arguments are used to shape their understanding of the use of incentives. The ‘lay ethical theories’ of our respondents leave open difficult questions about the nature of coercion and the distinctions between coercion, inducement, persuasion and rational response to behavioural and cognitive biases. It is possible, for instance, that an a priori concern with coercion in psychiatric practice disposes our respondents to identify new behavioural interventions as presumptively coercive. This would not mean that incentives are coercive on the best theoretical analysis of coercion, but it would mean that stakeholders are more likely to perceive, interpret and evaluate incentives using a ‘coercion frame’ rather than a ‘rational choice frame’. Since autonomy in the thin sense of the capacity to make unforced decisions made in light of the person's own preferences, and in the thick sense of being able to live in light of a coherent, reflectively endorsed set of values, is at the heart of psychiatry, it should not surprise us that a complex negotiation over what it requires takes place when incentives are proposed.