Decisions concerning children in the health care setting have engendered significant controversy and sparked ethics policies and statements, legal action, and guidelines regarding who ought to make decisions involving children and how such decisions ought to be made. Traditionally, parents have been the default decision-makers for children not only with regard to health care but with regard to other matters, such as religious practice and education. In recent decades, there has been a steady trend away from the view that parents (...) are in authority over their children and toward the view that children are rights-bearers who should be granted greater authority over themselves. The mature minor doctrine refers to the decision to grant mature minors the authority to make decisions traditionally reserved for their parents. This essay (1) documents the trend towards expanding the understanding of some minors as “mature” and hence as having the right and authority to give informed consent, (2) examines the reasons for which some commentators have a special interest in expanding the mature minor doctrine to the research setting and allowing minors to enroll in research without parental permission, and (3) defends the view that the mature minor doctrine, regardless of its application to clinical health care decisions, ought to be set aside in the research setting in favor of greater parental involvement. (shrink)

Some are concerned about the possibility that offering money for research participation can constitute coercion or undue influence capable of distorting the judgment of potential research subjects and compromising the voluntariness of their informed consent. The author recognizes that more often than not there are multiple influences leading to decisions, including decisions about research participation. The concept of undue influence is explored, as well as the question of whether or not there is something uniquely distorting about money as opposed to (...) a chance for treatment or medical care. An amount of money that is not excessive and is calculated on the basis of time or contribution may, rather than constitute an undue inducement, be an indication of respect for the time and contribution that research subjects make. (shrink)

Incentive programs have been criticized due to concerns that extrinsic rewards can ‘crowd out’ intrinsic motivation, and also that such programs might exert a corrupting influence on those receiving the incentive. Jonathan Wolff has argued that while these worries are in some instances well grounded, incentives can also operate by liberating people from social pressures that stand in the way of their intrinsic motivations. We further develop Wolff's insight by articulating a framework for assessing such incentives and discussing several areas (...) of public health where incentives may play a positive role. In so doing, we describe the limitations of Wolff's thesis as well as the opportunities it presents. Finally, we suggest that there is an additional attractive feature of incentives that has been overlooked, which is their capacity to serve as ‘conversation makers’. By providing people an occasion to discuss reasons for and against various health behaviors, incentives have the potential not only to impact the health behavior of individuals but to affect cultural change at the population level. (shrink)

Book reviewed in this article: Principles of Biomedical Ethics. By Tom L. Beauchamp and James F. Childress.

Background: Giving money as a direct incentive for patients in exchange for depot medication has proved beneficial in some clinical cases in assertive outreach . However, ethical concerns around this practice have been raised, and will be analysed in more detail here.Method: Ethical concern voiced in a survey of all AO teams in England were analysed regarding their content. These were grouped into categories.Results: 53 of 70 team managers mentioned concerns, many of them serious and expressing a negative attitude towards (...) giving money for depot adherence. Four broad categories of ethical concern following Christensen’s concept were distinguished: valid consent and refusal , psychiatric paternalism , resource allocation , organisational relationships , with a residual category others and unspecified .Discussion: The main concerns identified are discussed on the background of existing ethical theories in healthcare and the specific problems of community mental health and AO. Points for practice are derived from this discussion. A way forward is outlined that includes informed consent and an operational policy in the use of incentives, further randomised controlled trials and qualitative studies, and continuing discussions with all stakeholders, especially service users. (shrink)

In his Tanner Lecture of 1979 called ‘Equality of What?’ Amartya Sen asked what metric egalitarians should use to establish the extent to which their ideal is realized in a given society. What aspect of a person’s condition should count in a fundamental way for egalitarians, and not merely as cause of or evidence of or proxy for what they regard as fundamental?

There is an alleged tension between undue inducement and exploitation in research trials. This paper considers claims that increasing the benefits to research subjects enrolled in international, externally-sponsored clinical trials should be avoided on the grounds that it may result in the undue inducement of research subjects. This article contributes to the debate about exploitation versus undue inducement by introducing an analysis of the available empirical research into research participants' motivations and the influence of payments on research subjects' behaviour and (...) risk assessment. Admittedly, the available research in this field is limited, but the research that has been conducted suggests that financial rewards do not distort research subjects' behaviour or blind them to the risks involved with research. Therefore, I conclude that research sponsors should prioritise the prevention of exploitation in international research by providing greater benefits to research participants. (edited). (shrink)

Using payment to recruit research subjects is a common practice, but it raises ethical concerns that coercion or undue inducement could potentially compromise participants’ informed consent. This is the first national study to explore the attitudes of IRB members and other human subjects protection professionals concerning whether payment of research participants constitutes coercion or undue influence, and if so, why. The majority of respondents expressed concern that payment of any amount might influence a participant’s decisions or behaviors regarding research participation. (...) Respondents expressed greater acceptance of payment as reimbursement or compensation than as an incentive to participate in research, and most agreed that subjects are coerced if the offer of payment makes them participate when they otherwise would not or when the offer of payment causes them to feel that they have no reasonable alternative but to participate . Views about undue influence were similar. We conclude that human subjects protection professionals hold expansive and inconsistent views about coercion and undue influence that may interfere with the recruitment of research participants and impede valuable research. (shrink)