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Original papers: Dirk Claassen, Walid K. Fakhoury, Richard Ford, and Stefan Priebe Money for medication: financial incentives to improve medication adherence in assertive outreach Psychiatr Bull 2007; 31: 4-7 [Abstract] [Full text] [PDF]

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Money for Medication: an ethical dilemma

Giles S Berrisford   (16 February 2007)

Money for Medication: an ethical dilemma 16 February 2007
Giles S Berrisford, Specialist Registrar Queen Elizabeth Psychiatric Hospital, Edgbaston, Birmingham Send letter to journal: Re: Money for Medication: an ethical dilemma giles.berrisford{at}bsmht.nhs.uk Giles S Berrisford	Classen et al state that financial incentives to increase adherence to depot medication should be considered further and welcome a debate upon the ethical implications of this management strategy (Psychiatric Bulletin, January 2007, 31, 4-7). They identify autonomy, as defined by Beauchamp’s four-principles approach, as a specific area of concern (Beauchamp, 2003). The key issue here therefore is whether the payment is coercive or not. If it is coercive, the individual’s ability to act autonomously has been reduced. Classen et al use Wertheimer’s definition that “threats coerce but offers do not;” with a threat being an action that makes the individual worse off than at baseline, while an offer does not (Wertheimer, 1993). Classen et al argue therefore that the offer is not coercive and is therefore ethically neutral. It can be argued however, that routine payment for receiving a depot will become the new baseline rendering the removal of payment a threat. Removal of payment therefore becomes coercive, reducing autonomy. The loss of money is minimised by Classen because of its small monetary value causing its removal to be seen as non-threatening. However, this contradicts the hypothesis that it is the money that encourages the individual to accept the depot. Inevitably the use of payment will be coercive for some groups, reducing their autonomy but simultaneously promoting access to essential treatment, in-keeping with Beauchamp’s principle of justice. A tension clearly exists between the principles of autonomy and justice; this is brought into sharper focus for disenfranchised, economically deprived groups. BEAUCHAMP, T.L. (2003) Methods and principles in biomedical ethics. Journal of Medical Ethics, 29, 269-274. WERTHEIMER, A. (1993) A philosophical examination of coercion for mental health issues. Behavioural sciences and the law, 11, 239-258.