Controversies still exists within the research fraternity on the form and level of incentives, compensation and reimbursement to study participants in resource-constrained settings. While most research activities contribute significantly to advancement of mankind, little has been considered in rewarding directly the research participants from resource-constrained areas. A study was conducted in Zimbabwe to investigate views and expectations of various stakeholders on study participation incentives, compensation and reimbursement issues. Data was collected using various methods including a survey of about 1,008 parents/guardians (...) of school children participating in various immunological cohort studies and parasitology surveys. Community advisory boards (CABs) at 9 of the sites were also consulted. Further, information was gathered during discussions held at a basic research ethics training workshop. The workshop had 45 participants that including 40 seasoned Zimbabwean researchers and 5 international research collaborators. About 90% (907) of the study participants and guardians expected compensation of reasonable value, in view of the researchers' value and comparison to other sites regardless of economic status of the community. During discussion with researchers at a basic ethics training workshop, about 80% (32) believed that decisions on level of compensation should be determined by the local research ethics committees. While, the few international research collaborators were of the opinion that compensation should be in accordance with local guidelines, and incentives should be in line with funding. Both the CAB members and study participants expressed that there should be a clear distinction between study incentive and compensation accorded to individual and community expectations on benefits from studies. However, CABs expressed that their suggestions on incentives and compensation are often moderated by the regulatory authorities who cite fear of unknown concerns. Overall, both personal and community benefits need to be considered colectively in future studies to be conducted in resource-constrained communities. There is projected fear that recruitment in future may be a challenge, now that almost every community, has somehow been reached and participated in some form of studies. A major concern on reimbursement, compensation or incentives should be internationally pegged regardless of different economic status of the individuals or communities where the study is to be conducted. (shrink)

The proposed framework by Lynch et al. (2021) for promoting ethical forms of payment in Human Infection Controlled Studies (HICS) in general and SARS-Cov-2 HICS in particular is an important contri...

The paper by Lynch et al. argues that payments to research participants in biomedical research can be divided into three different categories, reimbursement, compensation, and incentive and...

Chronic shortage in organs for transplantation worldwide is leading many policy-makers to consider various incentives that may increase donation rates.1 These range from giving holders of donor cards some priority on the transplant waiting list or a discount on health insurance premiums, to giving families who consent to donation a medal of honour, reimbursement of funeral expenses, tax incentives or even financial compensation.2–4 Of the various proposed incentive mechanisms, the one that has consistently garnered the most criticism and objection (...) in the literature is that of paying families who consent to donate the organs of a deceased loved one.Arguments against such a policy abound: it could exploit the poor, influence the family to prematurely withdraw care, encourage families to withhold medical information that would result in transplant-transmission of disease, and finally, it would commercialise the value of human life and result in the perception of human organs as commodities. Indeed, to date no Western country has adopted a policy of financial compensation to families for consenting to organ donation.2Recently, a country suffering from severe shortage in organs has implemented a policy of financial incentives that uses cash payments. Wu and Fang5 describe a recent pilot programme in China that compensates families for postmortem donation, through an independent third party and based on consent or presumed consent of the deceased. The particular context within which this programme is implemented validates and even exacerbates some ethical concerns that have been voiced in the Western medical and bioethics …. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Kennedy Institute of Ethics Journal 13.1 (2003) 53-64 [Access article in PDF] Incentives for Providing Organs Patricia Milmoe McCarrick and Martina Darragh After a contentious debate at its 2002 annual meeting, the American Medical Association's House of Delegates voted to endorse the opinion of its Council on Ethical and Judicial Affairs that the impact of financial incentives on organ donation should be studied (Josefson 2002). The shortage of organs (...) for transplantation has been an ongoing problem for more than 20 years. In June1981, Representative Philip Crane (R-IL) introduced legislation in the U.S. House of Representatives proposing a $25,000 income tax deduction and a $25,000 estate tax exclusion for donating an organ (Tax Incentives 1981). Still the National Organ Transplant Act enacted in October 1984 prohibited the offering of any "valuable consideration" in return for organs (United States 1984).The developments of a legal market for tissues in the United States and a black market for organs around the world have raised the question of whether donation without compensation is the only ethically viable option. Some critics of the current system claim reliance on donation actually promotes a black market in organs (Kaserman and Barnett 2002, p. 38; Palmer 1999, p. 36). In addition, a new set of compensation issues has arisen as living kidney donor transplantations begin to rival those performed with cadaveric organs (United States 2001).As a result, current suggestions for incentives go far beyond the traditional death benefit payment to include such ideas as medals of honor for donors, reimbursement for funeral expenses, exchange programs for organ donation, and special medical insurance for living organ donors. Numerous bills introduced into the 107th Congress have proposed such incentives (Delmonico et al. 2002.) In October 2002, the U.S. Department of Health and Human Services awarded $5.2 million in grants to study both clinical and behavioral interventions for increasing organ donations that do not involve incentives. The inspiration for some of the funded proposals comes from the successes of Spain's social services and the United Kingdom's clinical administration of organ procurement programs (Robeznieks 2002). [End Page 53]With a nod to evidence-based medicine, the underlying concern expressed in much of the current literature is that no idea for increasing the supply of organs should be discounted before it is studied. This bibliography provides a short introduction to the range of opinions expressed on the issue of incentives for providing organs.al-Mousawi, M.; Samhan, M.; al-Mezairee I.; Razzak, M.A.; and Khawari, F. Cadaver Organ Procurement in Kuwait. Transplantation Proceedings 31 (8): 3375-76, 1999.The authors describe a protocol that significantly increased cadaveric organ donation and credit it with fostering the expansion of an organ sharing program among the Arab Gulf states. Developed by Kuwaiti neurologists and anesthetists after a continuing education course on transplantation, the protocol places a special emphasis on the role of local transplant coordinators who facilitate the investigation of brain death cases by neurologists.Arnold, Robert; Bartlett, Steven; Bernat, James; et al. [Ethics Committee of the American Society of Transplant Surgeons] Financial Incentives for Cadaver Organ Donation: an Ethical Reappraisal. Transplantation 73 (8): 1361-67, 27 April 2002.To prepare for proposed studies of financial incentives for organ donation, the American Society of Transplant Surgeons convened a panel to develop a methodology for evaluating the ethics of such research. Comprised of organ procurement organization executives, physicians, surgeons, and ethicists, the panel generated a list of nine criteria for use in judging any incentives proposal. While opposed to direct payment or tax incentives for organ donation, a majority of the members support funeral expense reimbursement or charitable contributions as incentives that would not violate or undermine the ideal of altruism.Cameron, J. Stewart, and Hoffenberg, Raymond. The Ethics of Organ Transplantation Reconsidered: Paid Organ Donation and the Use of Executed Prisoners as Donors. Kidney International 55 (2): 724-32, February 1999.After reviewing arguments for and against payment for organ procurement, the authors apply these arguments to the specific case of obtaining organs from executed... (shrink)

An ethical issue that has largely been overlooked and neglected is the potential conflict of interests faced by medical professionals in the recruitment, counselling and reimbursement of egg donors. It must be noted that fertility treatment in private practice is an overwhelmingly profit-driven enterprise. To attract more patients and generate more income, there is a strong incentive for fertility clinics and doctors to actively and aggressively recruit women for their egg donation programme. In some countries where substantial financial remuneration (...) for egg donation is permitted—for example, the United States,1 2 fertility doctors and clinical embryologists often act as the “middleman” or broker to facilitate the transaction of eggs between donor and recipient. Very often, the usual practice is for fertility clinics to charge patients a commission for sourcing egg donors, which is an additional profit on top of substantial medical fees that would be earned from provision of fertility treatment to the same patient. This is ethically contentious; because the money earned is not directly related to medical services rendered to the patient, but is instead attributed to the brokerage and transaction of donated human material.There is a risk that the welfare of the …. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Kennedy Institute of Ethics Journal 13.1 (2003) 51-52 [Access article in PDF] Congress Considers Incentives for Organ Procurement Alexander S. Curtis [Tables]During the 108th Congressional session, several bills pertaining to ethical incentives for organ donation likely will be introduced. In some cases, they will be similar to bills before the 107th Congress (see Table 1). Bills in both the House of Representatives and the Senate address the establishment and (...) maintenance of donor registries, financial reimbursements for medical and nonmedical expenses incurred by qualifying donors, the presentation of commemorative medals, and tax credits.A bill entitled "Gift of Life Congressional Medal Act" (introduced last year by Senate majority leader Bill Frist (R-TN) as Senate Bill 325), and its corresponding bill of the same title (passed in the House of Representatives last year as H.R. 708), would establish a congressional commemorative medal honoring "any organ donor, or the family or family member of any organ donor." The medal is to be designed and struck with "suitable emblems, devices, and inscriptions" by the Secretary of the Treasury. The eligible donor or donor's family member would be presented with the medal by the Secretary of Health and Human Services. This bill would establish qualifying donations as those of human kidneys, livers, hearts, lungs, pancreases, or any other organ, but excludes corneas and eyes.Another bill, introduced by Representative Michael Bilirakis (R-FL) entitled "Organ Donation Improvement Act" (H.R. 624), would award grants or contracts to states, transplant centers, and qualified organ procurement organizations for the purpose of providing travel, subsistence, and incidental nonmedical expenses to individuals who make living donations. In order to receive reimbursement, the donating individuals must reside in states other than the states in which the intended recipients reside and the annual income of those receiving the organs cannot exceed $35,000. The bill also would appropriate $15,000,000 to make grants to states and public and nonprofit entities for the purpose of carrying out studies, public education demonstrations, and outreach activities "designed to increase the number of organ donors within the state." The bill would be effective from time of enactment through 2005. [End Page 51]Two other bills proposed within the House of Representatives in 2002 called for amendment to the Internal Revenue Code. The "Gift of Life Tax Credit Act (introduced as H.R. 1872 by Representative James Hansen (R-UT)) and the "Help Organ Procurement Expand Act" (introduced as H.R. 2090 by Representative Chris Smith (R-NJ)) present a refundable credit to individuals or to the estates of those who agree either to be living donors or to donate their organs upon death. The "Gift of Life Tax Credit Act" refunds $10,000 to the estates of eligible individuals "for the taxable year which includes the date of the individual's death." The "Help Organ Procurement Expand Act" offers a refund of $2,500 to qualified persons. Donations of kidneys, livers, pancreases, islet cells, lungs, and intestines are accepted, however several conditions restrict permissible donors. The "Gift of Life Tax Credit Act" requires that the legally competent individual's death not be due to a suicide and that the intention to donate was clearly declared. The "Help Organ Procurement Expand Act" prohibits donations from individuals who were killed with physician assistance, died as a result of a suicide, have been indicted or convicted of a felony or a misdemeanor offense, or are actively under criminal investigation for a possible felony offense. The "Help Organ Procurement Expand Act" also restricts procuring organs from unborn children or human fetuses and under circumstances in which the living donor would be subject to "unacceptable levels of medical risk of death or permanent debilitation." Alexander S. Curtis is a research assistant at the Kennedy Institute of Ethics, Georgetown University, Washington, DC. He received his bachelor's degree from Miami University.... (shrink)

Within international development [1], public health [2], and clinical medicine [3]–[5], there is increasing interest in determining whether cash payments or other economic incentives can be used to influence the choices and behavior of individuals and groups in order to promote desired health goals. However, a number of complex issues affect the review and approval by research ethics committees of research studying the effectiveness of using financial incentives to promote desired health goals. Current ethical and regulatory frameworks regard the provision (...) of gifts or cash payments to participants in human research as potentially problematic. Specifically, these frameworks imply that such incentives may undermine the autonomy of participant choice, hinder the disclosure of medical information, exacerbate social inequalities, or result in the exploitation or degradation of vulnerable populations [6]–[9]. Typically, these frameworks provide guidance about payment to research participants to reimburse expenses, to compensate for time and effort, to provide insurance coverage, or as an incentive to participate in the research itself. However, the issue of payment as a component of the research intervention is relatively new. RECs thus lack explicit guidance about ethical issues surrounding research that evaluates the use of financial incentives as an intervention to promote health. (shrink)

Recognising that offers of payment to research participants can serve various purposes—reimbursement, compensation and incentive—helps uncover differences between participants, which can justify differential payment of participants within the same study. Participants with different study-related expenses will need different amounts of reimbursement to be restored to their preparticipation financial baseline. Differential compensation can be acceptable when some research participants commit more time or assume greater burdens than others, or if inter-site differences affect the value of compensation. Finally, it may be (...) permissible to offer differential incentive payments if necessary to advance the goals of a study. We encourage investigators and Institutional Review Boards to think about whether to offer payment, in what amounts and for what purpose, and also to consider whether differential payment can help promote the scientific and ethical goals of clinical research. (shrink)

Recognizing that offers of payment to research participants can serve various purposes—reimbursement, compensation, and incentive—helps uncover differences between participants that can justify differential payment of participants within the same study. Participants with different study-related expenses will need different amounts of reimbursement to be restored to their pre-participation financial baseline. Differential compensation can be acceptable when some research participants commit more time or assume greater burdens than others, or if inter-site differences affect the value of compensation. Finally, it may be (...) permissible to offer differential incentive payments if necessary to advance a study’s goals. We encourage investigators and Institutional Review Boards to think not only about whether to offer payment, in what amounts, and for what purpose, but also to consider whether differential payment can help promote the scientific and ethical goals of clinical research. (shrink)

Evidence-based medicine (EBM), by its ability to decrease irrational variations in health care, was expected to improve healthcare quality and outcomes. The utility of EBM principles evolved from individual clinical decision-making to wider foundational clinical practice guideline applications, cost containment measures, and clinical quality performance measures. At this evolutionary juncture one can ask the following questions. Given the time-limited exigencies of daily clinical practice, is it tenable for clinicians to follow guidelines? Whose or what interests are served by applying performance (...) assessments? Does such application improve medical care quality? What happens when the best interests of vested parties conflict? Mindful of the constellation of socially and clinically relevant variables influencing health outcomes, is it fair to apply evidence-based performance assessment tools to judge the merits of clinical decision-making? Finally, is it fair and just to incentivize clinicians in ways that might sway clinical judgment? To address these questions, we consider various clinical applications of performance assessment strategies, examining what performance measures purport to measure, how they are measured and whether such applications demonstrably improve quality. With attention to the merits and frailties associated with such applications, we devise and defend criteria that distinguish between justice-sustaining and justice-threatening performance-based clinical protocols. (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)

In this paper, I claim that live uterus donors ought to be considered for the possibility of compensation. I support my claim on the basis of comparable arguments which have already been applied to gamete donation, surrogacy, and other kinds of organ donation. However, I acknowledge that there are specificities associated with uterus donation, which make the issue of incentive and reward a harder ethical case relative to gamete donation, surrogacy, and other kinds of organ donation. Ultimately, I contend (...) that while reimbursement for the costs incurred by live uterus donors should be treated as a necessary ethical minimum, how much further we ought to remunerate uterus donations remains an open question. (shrink)

Americans are increasingly turning to hospice services to provide them with medical care, pain management, and emotional support at the end of life. The increase in the rates of hospice utilization is explained by a number of factors including a “hospice movement” dating to the 1970s which emphasized hospice as a tool to promote dignity for the terminally ill; coverage of hospice services by Medicare beginning in 1983; and, the market for hospice services provision, sustained almost entirely by governmental reimbursement. (...) On the one hand, the growing acceptance of hospice may be seen as a sign of trends giving substance to the death-with-dignity movement and the growing strength of end-of-life decision-makers and planners who integrate medical, community, family and spiritual networks. On the other hand, the precise relationship between the death-with-dignity and commercial processes driving hospice utilization rates are not well understood. On May 2, 2013, the U.S. Government intervened in a lawsuit brought by former hospice employees alleging that behind Vitas Innovative Hospice Care, the largest for-profit hospice service provider in the United States, lie an intricate web of incentives for patient intake nurses, physicians and marketers which not only drove hospice patients to use more expensive crisis care services, but influenced patient and family decisions as to whether or not to discontinue curative treatment. The corporate, investment, and regulatory history behind Vitas provides an important insight into the market realities behind Americans' embrace of hospice care and the risks to patient autonomy and health that accompany the commercialization of this ethically and morally complex health care service. (shrink)

The bioethics literature on managed care has devoted significant attention to a broad range of conflicts that managed care is perceived to have introduced into the practice of medicine. In the first part of this paper we discuss three kinds of conflict of interest: conflicts of economic incentives, conflicts with patient and physician autonomy, and conflicts with the fiduciary character of the physician–patient relationship. We argue that the conflicts are either not as serious as they are often alleged to be (...) or not unique to managed care. In part two we argue that managed care represents a new paradigm for medical care that features a new concept of management. We discuss three types or levels of management that managed care highlights, namely, administrative, clinical, and resource, which together offer a more sophisticated vantage point from which to assess patient care. We do not endorse managed care, but attempt to highlight some of the positive changes brought by managed care that were difficult to attain under traditional reimbursement systems. (shrink)

Prescribing drugs for uses that the FDA has not approved — off-label drug use — can sometimes be justified but is typically not supported by substantial evidence of effectiveness. At the root of inappropriate off-label drug use lie perverse incentives for pharmaceutical firms and flawed oversight of prescribing physicians. Typical reform proposals such as increased sanctions for manufacturers might reduce the incidence of unjustified off-label use, but they do not remove the source of the problem. Public policy should address the (...) cause and control the practice. To manage inappropriate off-label drug use, off-label prescriptions must be tracked in order to monitor the risks and benefits and the manufacturers’ conduct. Even more important, reimbursement rules should be changed so that manufacturers cannot profit from off-label sales. When off-label sales pass a critical threshold, manufacturers should also be required to pay for independent testing of the safety and effectiveness of off-label drug uses and for the FDA to review the evidence. Manufacturers should also finance, under FDA supervision, programs designed to warn physicians and the public about the risks of off-label drug use. (shrink)

Payment reforms that link health care providers’ reimbursements to their performance on various metrics incentivize providers to improve the quality and efficiency of care they provide to patients. Unfortunately, these reforms also create strong incentives for providers to reject patients who do not adhere to medical advice. This commentary argues that providers’ avoidance of non-adherent patients flouts the medical profession's commitment to patients’ best interests, undermines patients' trust in health professionals, and aggravates disparities in health. Moreover, the economic incentives under (...) payment reforms that encourage quality and efficiency gains are weakened when providers can escape the financial penalties for poor outcomes by simply firing their non-adherent patients. (shrink)

There is an ever increasing shortage of human organ transplants in Germany. This paper aims at understanding the reasons for that shortage better and then discusses various ways to overcome it. After estimating the potential supply of donor organs it is discussed why actual supply remains far below potential supply. Insufficient reimbursement for hospitals, a lack of incentives to donate, and mistaken donation rules are diagnosed to cause the shortage. Thus, organ shortage is due not to natural constraints but to (...) inappropriate social institutions. Introducing a presumed consent rule, reciprocity in organ allocation, better payments for hospitals and for donors seem potential remedies. (shrink)

Objective: To examine current research payment practices and to inform development of clearer guidelines for researchers and ethics committees.Design: Exploratory email based questionnaire study of current research participant reimbursement practices. A diverse sample of organisations and individuals were targeted.Setting: Australia.Participants: Contacts in 84 key research organisations and select electronic listservers across Australia. A total of 100 completed questionnaires were received with representations from a variety of research areas .Main measurements: Open-ended and fixed alternative questions about type of research agency; type (...) of research; type of population under study; whether payment is standard; amounts and mechanisms of payment; factors taken into account when deciding on payment practices; and whether payment policies exist.Results: Reimbursement practice is highly variable. Where it occurs it is largely monetary and is for time and out-of-pocket expenses. Ethics committees were reported to be often involved in decision making around reimbursement.Conclusions: Research subject payment practices vary in Australia. Researchers who do provide payments to research participants generally do so without written policy and procedures. Ethics committees have an important role in developing guidelines in this area. Specific guidelines are needed considering existing local policies and procedures; payment models and their application in diverse settings; case study examples of types and levels of reimbursement; applied definitions of incentive and inducement; and the rationale for diverse payment practices in different settings. (shrink)

Background The twenty-first century has witnessed an exponential increase in healthcare quality research. As such activities become more prevalent, physicians are increasingly needed to participate as subjects in research and quality improvement (QI) projects. This raises an important ethical question: how should physicians be remunerated for participating as research and/or QI subjects? Financial versus non-monetary incentives for participation Research suggests participation in research and QI is often driven by conditional altruism, the idea that although initial interest in enrolling in research (...) is altruistic or prosocial, decisions to actually perform study tasks are cost–benefit driven. Thus, the three models commonly employed to appropriately compensate participants (in-kind compensation such as travel reimbursement, paying market rates for the subject’s time, and paying market rates for the activity asked of the participant) are a poor fit when the participant is a clinician, largely due to the asymmetry between cost and benefit or value to the participant. Non-monetary alternatives such as protected time for participation, continuing education or maintenance of certification credit, or professional development materials, can provide viable avenues for reducing this asymmetry. Conclusion Research and QI are integral to the betterment of medicine and healthcare. To increase physician participation in these activities as the subject of study, new models are needed that clarify the physician’s role in research and QI as a subject. Non-monetary approaches are recommended to successfully and ethically encourage research and QI participation, and thus incorporate these activities as a normal part of the ethical clinician’s and successful learning healthcare system’s world view. (shrink)

The Diagnosis Confirmation Model includes a dual-pricing mechanism designed to support value-based pricing of novel antibiotics while improving the alignment of financial incentives with their optimal use in patients at high risk of drug-resistant infections. DCM is a market-based model and complementary to delinked models. Policymakers interested in stimulating antibiotic innovation could consider tailoring the DCM to their reimbursement systems and incorporating it into the suite of incentives to improve the economics of antibiotics.

In June 2021, an 1856 British Guiana 1c magenta stamp sold for US$8.3m. It is the only known specimen of its kind in existence and on a gram-for-gram basis the most valuable item in the world. Clearly, in some spheres of human engagement, rarity carries a premium. Should this logic be applied in healthcare? Magalhaes thinks not.1 They explore the topic of whether pricing and reimbursement systems should give a premium to orphan drugs for rare diseases. They argue that rarity (...) is irrelevant to pharmaceutical policy on ethical grounds, and instead drug incentives should be prioritised by disease severity. At a time when incentives for orphan medicines are being revisited globally, Magalhaes is provoking an important discussion. The author seeks to disentangle the interwoven concepts of rarity, severity and unmet need that factor into decisions on orphan drug policy. They perhaps overstate the emphasis on rarity within existing regulatory and P&R frameworks. Yes, this is one of the criteria for orphan drug designation, but in payer systems rarity is seldom explicitly referenced. For example, of the five largest European countries, only the United Kingdom formally adjusts willingness-to-pay thresholds by prevalence. In contrast, concepts of severity and unmet need feature widely in global regulatory processes (eg, Breakthrough Therapy designation from …. (shrink)

Definition of the problem: Rationing medical health care has been debated in the industrialized Western hemisphere for at least two decades. Many factors have contributed to the fact that medical care can no longer be provided free of charge, which used to be an explicit political goal in all countries with a well-established welfare system. Considerable shortage of public financial resources is now generally accepted to pertain also to the health care system. Arguments: So far, efforts have been made to (...) rationalize various medical procedures both with regard to specific medical treatment strategies and to administrative support processes. However, these means are limited in their effects to curb medical costs at a significant level. Thus, rationing medical health care is necessary to further enable the reimbursement system to cover expensive diagnostics and treatment that would exceed the individual’s capability to pay. Rationing can occur explicitly or implicitly. Implicit rationing has to be regarded as an unfair procedure and should be rejected on ethical grounds. Conclusion: Distributive justice in medical care can only be accomplished if the reimbursement system is based on a new theoretical foundation. This entails a stronger emphasis on individual responsibility for one’s own life and health and the insight that health is an individual rather than a collective good. Nevertheless, a mutual insurance-based collective health care system should not be abolished as long as it is thoroughly reformed. As a minimum requirement, it must provide incentives to spend money on preventive health measures. (shrink)

This brief review of the efficacy, safety, and costs of IVF demonstrates that this procedure has become accepted medical practice without adequate scientific assessment. Its rapid proliferation especially in the market-oriented USA system, has preceded the type of outcomes research that is essential in order to protect both individual patients and the health care system. In addition, concern over the psychological costs borne by the vast majority of women who unsuccessfully pursue pregnancy through these techniques should warrant a level of (...) caution which to date has not been forthcoming. The demand for pregnancy, the organisation of medical specialties surrounding these procedures, the open-ended reimbursement and incentive structure, and powerful market forces make it unlikely that IVF and a whole range of medical technologies can be regulated without some semblance of a national health system. These findings clearly reinforce the themes raised by the Radical Statistics Health Group and illustrate some of the weaknesses of a market approach to medical care. (shrink)

While different positions on the permissibility of organ markets enjoy support, there is widespread agreement that some benefits to living organ donors are acceptable and do not raise the same moral concerns associated with organ markets, such as exploitation and commodification. We argue on the basis of two distinctions that some benefit packages offered to donors can defensibly surpass conventional reimbursement while stopping short of controversial cash payouts. The first distinction is between benefits that defray the costs of donating an (...) organ and benefits that incentivize donation by offer- ing something in excess of defraying. The second distinction is between benefits that compensate donors and benefits that are non-compensating. We argue that non-compensating benefits are innocent of moral concerns typically associated with controversial cash payouts, and thus may be a morally promising avenue for increasing rates of kidney donation to address the tragic results of undersupply. (shrink)

In this paper I propose to shed new light on the role of feeling in Kant’s psychology of moral motivation by focusing on the concept of an incentive (Triebfeder), a term he borrowed from one of his most important rationalist predecessors, Alexander Gottlieb Baumgarten. I argue that, similar to Baumgarten, Kant understands an incentive to refer to the ground of desire and that feelings function as a specific kind of ground within Kant’s psychology of moral action, namely as (...) the ‘impelling cause’ of desire. I claim that this interpretation has several advantages over the alternatives currently on offer in the literature. (shrink)

In Pacificare Health Systems, Inc. v. Jefrey Book, the US. Supreme Court ruled that the mandatory arbitration clause in an HMO contract should be enforced to compel a physician to arbitrate his RICO charges against the health plan, even though the clause could be construed to limit the arbitrator’s authority to award full damages under the RICO statute. The ruling could prevent physicians with health plan arbitration agreements from taking future reimbursement claims against insurance companies directly to court, even when (...) the allegations involve a potential statutory breach outside of the explicit scope of the provider contract.Dr. Book’s arbitration claim was part of a larger class action lawsuit filed in August of 2000 by a group of physicians and patients seeking reimbursement from eight managed care companies for unpaid health insurance claims. (shrink)

In Pacificare Health Systems, Inc. v. Jefrey Book, the US. Supreme Court ruled that the mandatory arbitration clause in an HMO contract should be enforced to compel a physician to arbitrate his RICO charges against the health plan, even though the clause could be construed to limit the arbitrator’s authority to award full damages under the RICO statute. The ruling could prevent physicians with health plan arbitration agreements from taking future reimbursement claims against insurance companies directly to court, even when (...) the allegations involve a potential statutory breach outside of the explicit scope of the provider contract.Dr. Book’s arbitration claim was part of a larger class action lawsuit filed in August of 2000 by a group of physicians and patients seeking reimbursement from eight managed care companies for unpaid health insurance claims. (shrink)

There are marked differences between countries with regard to reimbursement decision-making, yet few studies have tried to understand this process and its consequences by a detailed analysis of the local context and decision-making structure. This article describes reimbursement decision-making and subsequent prescribing patterns of new pharmaceuticals by means of a case study on glitazones in treatment of type 2 diabetes mellitus patients in Denmark. The study shows that institutional arrangements, providing the context in which evidence is used, are highly important (...) for understanding the reimbursement decision-making process. In particular the Danish Medicines Agency (DMA) has shaped the decision to reimburse glitazones on the basis of physician-mediated requests of individual patients. Relatively few patients have been prescribed glitazones since their introduction in 2000, suggesting that individual reimbursement may be an effective instrument in controlling overall expenditure of selected pharmaceuticals, although in the case of glitazones this has likely been achieved at the expense of equality in access to the products. The discussion focuses on the generalizability of the findings to both other pharmaceuticals in the individual reimbursement scheme in Denmark, and to other countries that are trying to balance the need to control overall pharmaceutical care expenditure with the need to secure equality in access to new drugs with therapeutic added value. (shrink)

This paper examines the relationship between CEO incentives and strong and weak corporate social performance. Using the KLD database we find that incentives have no significant relationship with strong social performance. Salary and long-term incentives have a positive association with weak social performance.

Health incentive schemes aim to produce healthier behaviors in target populations. They may do so both by making incentivized options more salient and by making them less costly. Changes in costs only result in healthier behavior if the individual rationally assesses the cost change and acts accordingly. Not all people do this well. Those that fail to respond rationally to incentives will typically include those who are least able to make prudent choices more generally. This group will typically include (...) the least advantaged more generally, since disadvantage inhibits one's effective ability to choose well and since poor choices tend to cause or aggravate disadvantage. Therefore, within the target population, health benefits to the better off may come at the cost of aggravated inequity. This is one instance of a problem I name the Able Chooser Problem, previously emphasized by Richard Arneson in relation to coercive paternalism. I describe and discuss this problem by distinguishing between policy options and their effects on the choice situation of individuals. Both positive and negative incentives, as well as mandates that are less than perfectly effective, require some sort of rational deliberation and action and so face the Able Chooser Problem. In contrast, effective restriction of what options are physically available, as well as choice context design that makes some options more salient or appealing, do not demand rational agency. These considerations provide an equity-based argument for preferring smart design of our choice and living environment to incentives and mandates. (shrink)

Rawls argues that ‘Parties in the original position would wish to avoid at almost any cost the social conditions that undermine self-respect’. But what are these social conditions that we should so urgently avoid? One evident candidate might be conditions of material inequality. Yet Rawls seems confident that his account of justice can endorse such inequalities without jeopardising citizens’ self-respect. In this article I argue that this confidence is misplaced. Unequalising incentives, I claim, jeopardise the self-respect of those least advantaged—at (...) least under a Rawlsian schema—by undermining the very processes by which Rawls hopes to make distributional inequalities and self-respect compatible. I begin by setting out Rawls’s distinct account of self-respect before moving to describe how Rawls expects the difference principle to support citizens’ in this regard. I then draw upon GA Cohen’s distinction between ‘strict’ and ‘lax’ interpretations of the difference principle to argue that the presence of unequalising incentives undermines both the direct and indirect support that the difference principle can offer to citizens’ self-respect. As such, I claim that Rawls must either weaken his endorsement of unequalising incentives, or risk violating his ‘prior commitment’ to avoiding social conditions harmful to citizens’ self-respect. (shrink)

Background Policies to use financial incentives to encourage healthy behaviour are controversial. Much of this controversy is played out in the mass media, both reflecting and shaping public opinion. Objective To describe UK mass media coverage of incentive schemes, comparing schemes targeted at different client groups and assessing the relative prominence of the views of different interest groups. Design Thematic content analysis. Subjects National and local news coverage in newspapers, news media targeted at health-care providers and popular websites between (...) January 2005 and February 2010. Setting UK mass media. Results The study included 210 articles. Fifteen separate arguments favourable towards schemes, and 19 unfavourable, were identified. Overall, coverage was more favourable than unfavourable, although most articles reported a mix of views. Arguments about the prevalence and seriousness of the health problems targeted by incentive schemes were uncontested. Moral and ethical objections to such schemes were common, focused in particular on recipients such as drug users or the overweight who were already stereotyped as morally deficient, and these arguments were largely uncontested. Arguments about the effectiveness of schemes and their potential for benefit or harm were areas of greater contestation. Government, public health and other health-care provider interests dominated favourable coverage; oppo- sition came from rival politicians, taxpayersÕ representatives, certain charities and from some journalists themselves. Conclusions Those promoting incentive schemes for people who might be regarded as ÔundeservingÕ should plan a media strategy that anticipates their public reception. (shrink)

Low-income environments have been associated with greater levels of impulsive behavior, which contribute to the higher debt and obesity rates that further perpetuate current wealth and health disparities. In this commentary, we describe how this might be explained by an appeal to “incentive hope” and the motivational drive toward consumption triggered by the future uncertainty these groups face.

In Rescuing Justice and Equality, G.A. Cohen argues that the incentive inequalities permitted by John Rawls's difference principle are unjust since people cannot justify them to their fellow citizens. I argue that citizens of a Rawlsian society can justify their acceptance of a wide range of incentive inequalities to their fellow citizens. They can do so because they possess the right to freedom of occupational choice, and are permitted – as a matter of justice – to exercise this (...) right by making occupational decisions on the basis of a wide range of values and preferences. (shrink)

This book, first published in 2006, examines the incentives at work in a wide range of institutions to see how and how well coordination is achieved by informing and motivating individual decision makers. The book examines the performance of agents hired to carry out specific tasks, from taxi drivers to CEOs. It investigates the performance of institutions, from voting schemes to kidney transplants, to see if they enhance general well being. The book examines a broad range of market transactions, from (...) auctions to labor markets, to the entire economy. The analysis is conducted using specific worked examples, lucid general theory, and illustrations drawn from news stories. Of the seventy different topics and sections, only twelve require a knowledge of calculus. The second edition offers new chapters on auctions, matching and assignment problems, and corporate governance. Boxed examples are used to highlight points of theory and are separated from the main text. (shrink)

Introduction Financial incentive schemes have been commonly used by the hearing aid industry as a way of encouraging device sales. These schemes can lead to a conflict of interest as the hearing device dispenser is torn between personal reward over the best interests of their client. This conflict of interest has the potential for the dispenser to develop “moral distress”, a negative state of mind when an individual’s ethical values contrast with those of the employing organization. The purpose of (...) this study was to investigate if there was a relationship between financial incentives and moral distress in Australian audiologists and audiometrists. Methods An online survey was distributed to all members of Audiology Australia and the Australian College of Audiology via email. Participants rated their perceived moral distress from 0 to 10 on the Moral Distress Thermometer and answered four questions about financial incentives in their respective workplace. Results A total of 65 participants, 42 females and 23 males, completed the online survey. A quarter of participants rated their moral distress corresponding to levels of uncomfortable or above. A statistically significant association was found between financial incentives, sales target setting, and higher perceived moral distress in participants. Conclusions For our sample, the implementation of financial incentives created ethical challenges for practicing audiologists and audiometrists. Modifications to employee rewards programs as well as a regulation of device sales are recommended. (shrink)

In a recent article, Seana Valentine Shiffrin offers a distinctive egalitarian critique of the types of incentive inequalities that are permitted by John Rawls's difference principle. She argues that citizens of a well-ordered society, who publicly accept Rawls's two principles of justice and their justifications, may not demand incentives to employ their talents in productive ways since such demands are inconsistent with a major justification for the difference principle: the moral arbitrariness of talent. I argue that there is no (...) such inconsistency. Citizens can publicly accept the claim that talent is morally arbitrary and accept incentives to employ their talents productively without inconsistency. In the standard case that Rawls envisions, citizens who do so take their preferences to be a reason for a higher salary, not their talents. (shrink)

Poor medication adherence in patients with a psychosis is associated with relapse. It has been proposed that outcomes might be improved by using financial incentives for treatment adherence (FITA). However, a strong moral intuition against this practice has been found. This paper examines the ethics of FITA. Three arguments are presented, which if accepted would severely restrict or even prohibit the practice. These are based on (1) “incommensurable values”, where FITA denigrates an aspect of “respect for the person”, (2) “exploitation”, (...) where unfair advantage is taken of the patient, and (3) “fairness”, where it is difficult to draw a line between those who should and should not be offered payment. A number of practical impediments are also considered. (shrink)

This paper explores how managers’ and supervisors’ equity incentives impact the likelihood of committing corporate fraud in Chinese-listed firms. Previous research has shown that corporate fraud in China is a widespread phenomenon and has severe consequences for affected firms and executives. However, our understanding of the reasons that fraud is committed in a Chinese setting has been very limited thus far. This is an increasingly important topic, because corporate governance is rapidly changing in China, and it is unclear whether adopting (...) the executive compensation practices of the West is appropriate for Chinese firms. We show that managers’ equity incentives increase their propensity to commit corporate fraud. We also find that this effect is more pronounced for state-owned firms. However, we find a negative but not significant relationship between the equity incentives of the supervisory board and the incidence of fraud. (shrink)

Hertwig and Ortmann suggest paying participants contingent upon performance in order to increase the thoroughness they devote to a decision task. We argue that monetary incentives can yield a number of unintended effects including distortions of the subjective representation of the task and impaired performance. Therefore, we conclude that performance-contingent payment should not be generally employed in judgment and decision research.

In Utopophobia Estlund offers a prominent version of a conditional account of feasibility. I think the account is too permissive. I defend an alternative incentives account of feasibility. The incentives account preserves the spirit of the conditional account but qualifies fewer actions as feasible. Simplified, the account holds that an action is feasible if there is an incentive such that, given the incentive, the agent is likely to perform the action successfully. If we accept that ought implies feasible, (...) then we should reject some normative requirements on agents that Estlund would accept in light of his more permissive conditional account. But we can still recognise normative requirements on individual and collective agents that, if complied with, would result in a world that is radically better than our own. (shrink)

In Rescuing Justice and Equality , G. A. Cohen reiterates his critique of John Rawls's difference principle as a justification for inequality-generating incentives, and also argues that Rawls's ambition to provide a constructivist defence of the first principles of justice is doomed. Cohen's arguments also suggest a natural response to my earlier attempt to defend the basic structure objection to Cohen's critique, which I term the alien factors reply. This paper criticises the reply, and Cohen's more general argument against Rawls's (...) constructivism. 1. (shrink)

Contemporary debates about scientific institutions and practice feature many proposed reforms. Most of these require increased efforts from scientists. But how do scientists’ incentives for effort interact? How can scientific institutions encourage scientists to invest effort in research? We explore these questions using a game-theoretic model of publication markets. We employ a base game between authors and reviewers, before assessing some of its tendencies by means of analysis and simulations. We compare how the effort expenditures of these groups interact in (...) our model under a variety of settings, such as double-blind and open review systems. We make a number of findings, including that open review can increase the effort of authors in a range of circumstances and that these effects can manifest in a policy-relevant period of time. However, we find that open review’s impact on authors’ efforts is sensitive to the strength of several other influences. (shrink)

An egalitarian interpretation and defence of Rawls's principles of justice and their institutional and policy implications in response to G. A. Cohen's criticisms of Rawls's alleged justification of unequalizing incentives. Keywords Applied Philosophy Social and Political Philosophy Rawls G.A. Cohen difference priciple incentives justice property-owning democracy.

An egalitarian interpretation and defence of Rawls's principles of justice and their institutional and policy implications in response to G. A. Cohen's criticisms of Rawls's alleged justification of unequalizing incentives.

Financial incentives and disincentives are fundamental to a category of proposals, usually characterised as forms of managed care, whereby the pecuniary interests of health care providers are directly affected by their clinical decision-making. Presently, Australian health care administrators and private insurers are adopting financial incentives as a means of ensuring provider compliance with ‘health outcome ’ and cost-constraint objectives. To the extent that this has occurred, health-care relationships are transformed to emulate, more closely, a commercial transaction.This paper questions the ideological (...) assumptions which inform the use of financial incentives in the health care domain and raises concerns with regard to the potential for financial incentives to undermine the moral integrity of clinical decision-making. It also challenges the legitimacy of rationing health care resources through the use of this measure, particularly when adopted by private insurers of health care. (shrink)

Monetary incentives to increase COVID-19 vaccinations are widely used. Even if they work, whether such payments are ethical is contested. This paper reviews ethical arguments for and against using monetary incentives that appeal to utility, liberty, civic responsibility, equity, exploitation, and autonomy. It concludes that in low-income nations and nations with meagre safety nets and income inequality, policy-makers should proceed with caution.

Robert Nozick declares that scanning complex wholes is not easy. Presumably few people exhibited the skill before Nozick, but I propose another explanation for why few people exhibit it than difficulty. Focusing specifically on scanning for inconsistencies, papers conveying them won’t look impressive to certain evaluators.