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Money for medication: financial incentives to improve medication adherence in assertive outreach

  • Dirk Claassen (a1), Walid K. Fakhoury (a2), Richard Ford (a3) and Stefan Priebe (a4)

Abstract

Aims and Method

Although financial incentives to improve treatment adherence have been found effective in various medical specialties, there are few systematic data on their use, ethical background and effectiveness in psychiatry. We explored the practice of and possible ethical problems associated with direct financial incentives to improve adherence in assertive outreach teams in England. We also report clinical observations of a money for medication scheme with five assertive outreach patients in East London.

Results

None of the assertive outreach teams that responded to the survey (response rate 47%) uses financial incentives. Attitudes of team managers towards the practice were mostly negative, often regarding it as unethical. Specific concerns were related to possible coercion and a negative impact on the therapeutic relationship. Out of five patients studied, four accepted the offer of money and had improved adherence; three remained without hospital admission since entering the scheme.

Clinical Implications

Money for medication might be a non-coercive and effective option to achieve medication adherence in otherwise non-adherent assertive outreach patients. However, ethical issues need further exploration and controlled trials are required to establish the effectiveness.

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Copyright

This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

References

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Money for medication: financial incentives to improve medication adherence in assertive outreach

  • Dirk Claassen (a1), Walid K. Fakhoury (a2), Richard Ford (a3) and Stefan Priebe (a4)
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eLetters

Money for Medication: an ethical dilemma

Giles S Berrisford, Specialist Registrar
16 February 2007

Classen et al state that financial incentives to increase adherence to depot medication should be considered further and welcome a debate uponthe 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.
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