Transcript Foundational Ethical Theories & Approaches

Incentivizing Treatment Compliance
and Healthy Behaviours
Barbara Russell, PhD (Phil) MBA
Bioethicist, Centre for Addiction and Mental Health
University of Toronto Joint Centre for Bioethics
Assistant Professor, University of Toronto’s Institute for Health Policy, Management & Evaluation
JEMH 2012 conference
Three Issues, Three Questions
1.
The catalyst, then and now
2.
Incentives at the individual level
3.
Incentives at the group level
References
Lucke & Hall (2012) Under What Conditions is it Ethical to Offer Incentives to Encourage Drug-Using
Women to Use Long-Acting Forms of Contraception? Addiction 107: 1036-41
Black, Haber & Lintzeris (2012) Offering Incentives to Drug-Using Women to Take Up Contraception: the
ethical and clinical issues, Addiction 107: 1361-2
Lucke & Hall (2012) Exploring Conditions Under Which It May Be Ethical to Offer Incentives to
Encourage Drug-Using Women to Use Long-Acting Forms of Contraception, Addiction 104: 1049-50
Paltrow (2012) Is it Ethical to Suggest that Some Women Need Incentives to Use Contraception or to be
Sterilized? Addiction 104: 1047-8
Temple & Hankins (2012) Promotion of Comprehensive and Prevention-Driven Approaches to Drug Use
and Unintended Pregnancy, Addiction 104: 1046-7
Heil & Higgins (2012) The Scientific and Ethical Rationale for Using Incentives to Promote Contraceptive
Use Among Drug-Using Women, Addiction 107: 1044-5
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Addiction 107: 1043-4
Diclemente & Young (2012) Incentivizing Drug-Using Women’s Long-Term Contraceptive Use: some
answers, more questions, Addiction 107: 1042-3
Blumenthal-Barby & Burroughs (2012) Seeking Better Health Care Outcomes: the ethics of using the
“nudge”, American Journal of Bioethics 12(2): 1-10
Sellinger & Whyte (2012) What Counts as a Nudge? American Journal of Bioethics 12(2): 11-2
Carter & Hall (2012) Avoiding Selective Ethical Objections to Nudges, American Journal of Bioethics
12(2): 12-4
DiSilvestro (2012) What Does Not Budge for Any Nudge? American Journal of Bioethics 12(2): 14-5
Verweij & van den Hoven (2012) Nudges in Public Health: paternalism is paramount, American Journal of
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promote public health, American Journal of Bioethics 12(2): 18-20
Rossi & Yudell (2012) Value-Ladenness and Rationality in Health Communication, American Journal of
Bioethics 12(2): 20-2
Huang & Baum (2012) Nudge Ethics: just a game of billiards? American Journal of Bioethics 12(2): 22-4
Axtell-Thompson (2012) Nudges Ethics for Health Plans, American Journal of Bioethics 12(2): 24-5
Klein (2012) Redefining the Clinical Relationship in the Era of Incentives, American Journal of Bioethics
12(2): 26-7
References
Stark (2012) Reconciling Bioethics with Health Care Strategies Born of Behavioral Economics and
Psychology, American Journal of Bioethics 12(2): 28-30
Castelo, Reiner & Felsen (2012) Balancing Autonomy and Decisional Enhancement: an evidence-based
approach, American Journal of Bioethics 12(2): 30-1
Whyte, Selinger, Caplan & Sadowski (2012) Nudge, Nudge or Shove, Shove: the right way for nudges to
increase the supply of donated cadaver organs, American Journal of Bioethics 12(2): 32-4
Potts, Veheijde & Rady (2012) When a Nudge Becomes a Shove, American Journal of Bioethics 12(2): 402
Vallgårda (2012) Nudge-a new and better way to improve health? Health Policy 104: 200-3
Nadler (2012) Cigarettes: nudge or shove? A neuro-perspective.
http://neuroethicscanada.wordpress.com/2012/03/08/graphic-warnings-on-cigarettes-nudge-or-shovea-neuro-perspective
Warren, Abuya, Obare, Sundy, Njue, Askew & Bellows (2011) Evaluation of the Impact of the Voucher and
Accreditation Approach on Improving Reproductive Behaviors and Status in Kenya, BMC Public Health
11: 177-85
Bellows, Warren, Vonthanak, Chhorvann, Sokhom, Men, Bahracharya, Rob & Rathavy (2011) Evaluation of
the Impact of the Voucher and Accreditation Approach on Improving Reproductive Behaviors and
Status in Cambodia, BMC Public Health 11: 667-77
Anderson (2010) Nudge: Improving Decisions about Health, Wealth and Happiness Review, Economics &
Philosophy 26(3): 369-76
Adams (2010) Why Drug Addicts are Getting Sterilized for Cash, Time online April 17
Marteau, Ashcroft & Oliver (2009) Using Financial Incentives to Achieve Health Behavior, British Medical
Journal 338: 983-6
Barnett, Sorenson, Wong, Haug & Hall (2009) Effects of Incentives for Medication Adherence on Health
Care Use and Costs in Methadone Patients with HIV, Drug & Alcohol Dependence 100(1-2): 115-21
Szmukler (2009) Financial Incentives for Patients in the Treatment of Psychosis, Journal of Medical Ethics
35(4): 224-8
Thaler & Sunstein (2008) Nudge: improving decisions about health, wealth and happiness. Yale University
Press.
Long, Helweg-Larsen & Volpp (2008) Patient Opinions Regarding “Pay for Performance for Patients”,
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Volpp, Loewenstein, Troxel, Doshi, Price, Laskin & Kimmel (2008) A Test of Financial Incentives to Improve
Warfarin Adherence, BMC Health Services Research 8: 272-7
Beier, Hidalgo & John (2008) Financial Incentives to Promote Prolonged Renal Graft Survival: potential for
patients and public health, Medical Hypotheses 70(2): 218-20
References
Claassen, Fakhoury, Ford & Priebe (2007) Money for Medication: financial incentives to improve
medication adherence in assertive outreach, Psychiatric Bulletin 31(1): 4-7
Claassen (2007) Financial Incentives for Antipsychotic Depot Medication: ethical issues, Journal of
Medical Ethics 33(4): 189-93
Collinson (2007) Incentives Help Vulnerable Patients to Stay Well, BMJ online 335: 317
Butsch, Ard, Allison, Patki, Henson, Rueger, Hubbert, Glandon & Heimburger (2007) Effects of a
Reimbursement Incentive on Enrollment in a Weight Control Program, Obesity 15(11): 2733-8
Burns &Shaw (2007) Is it Acceptable for People to be Paid to Adhere to Medication?, BMJ 335: 232-3
Rawson, McCann, Flammino, Shoptaw, Miotto, Reiber & Ling (2006) A Comparison of Contingency
Management and Cognitive-Behavioral Approaches for Stimulant-Dependent Individuals, Addiction
101(2): 267-74
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Substance Use Disorders: a meta-analysis, Addiction 101(11): 1546-60
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Therapy for Substance Use Disorders, Addiction 101(12): 191-203
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References
Fry, Hall, Ritter & Jenkinson (2006) The Ethics of Paying Drug Users Who Participate in Research: a
review and practical recommendations, Journal of Empirical Research on Human Research Ethics
online: 21-35
Morgan (2004) Payment of Drug Addicts to Increase their Sterilisation Rate is Morally Unjustified and Not
Simply ‘A Fine Balance”, Journal of Obstetrics and Gynaecology 24(2): 199-23
Schwartz (2004) The Paradox of Choice: why more is less. New York: HarperCollins.
Paltrow (2003) Why Caring Communities Must Oppose C.R.A.C.K.? Project Prevention: how C.R.A.C.K.
promotes dangerous propaganda and undermines the health and well being of children and families,
Journal of Law in Society 5: 11-117
Pugsley (2003-4) False Promises, Journal of Law in Society 5: 119-36
Boyer (2003) When Pregnant Women Use Drugs: what are the real problems and what society do to
solve them?, Journal of Law in Society 5: 137-53
Chelian (2003) Remarks on the “CRACK” Program: coercing women’s reproductive choices, Journal of
Law in Society 5: 187-98
Fenton (2003) Cash for Birth Control, A Solution or a Violation of Rights?, Journal of Law in Society 5:
199-227
References
Cummings (2003) Is CRACK the Cure?, Journal of Law in Society 5: 1-10
Mauldon (2003) Providing Subsidies and Incentives for Norplant, Sterilizations and Other Contraception:
allowing economic theory to inform ethical analysis, Journal of Law, Medicine & Ethics 31(3): 351-64
Sailer (2002) Q&A with Barbara Harris: paying cash to crack addicts for contraception,
www.isteve.com/2002_QA_Barbara_Harris.htm
Johnson (2001) Reproductive Ability for Sale, Do I Hear $200? Private case-for-contraception
agreements as an alternative to maternal substance abuse, Arizona Law Review 43: 205-4
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University Press.
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Rewards on Intrinsic Motivation, Psychological Bulletin 125(6): 627-68
Belluck (1999) Cash-for-Sterilization Plan Draws Addicts and Critics, New York Times July 24: 8
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Planning 26(6): 363-7
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JAMA 267(13): 1818-21
Stevens & Stevens (1992) Introductory Small Cash Incentives to Promote Child Spacing in India, Studies
in Family Planning 23(3): 171-86
1. The Catalyst, then and now
“Our Mission
[We] offer cash incentives to women and men addicted to drugs and/or alcohol
to use long term or permanent birth control. [C.R.A.C.K.] is a national 501
(C) 3 organization using your donations to stop a problem before it happens.
We have paid addicts in 50 States and the District of Columbia.
Our mission is to continue to reach out to addicts offering referrals to drug
treatment for those interested and to get them on birth control until they can
care for the children they conceive. We are lowering the number of children
added to foster care, preventing the addicts from the guilt and pain they feel
each time they give birth only to have their child taken away, and preventing
suffering of innocent children because even those fortunate enough to be
born with no medical or emotional problems after placed in foster care face
often a lifetime of longing to feel loved and wanted.”
Online website
“Project Prevention”
Use of C.R.A.C.K.
As of May 2012, incentives paid to 4,097 people
by gender: 4,025 women
72 men
by race/ethnicity: 2,180
987
506
424
white
black
Hispanic
other
by procedure: 1,507 surgery (1,435 tubal ligations, 72 vasectomies)
1,229 device (IUD)
1,361 pharmacology (1,059 Depro Provera, 264 implanon,
38 Norplant)
www.projectprevention.org
C.R.A.C.K. Chair’s comments during interviews
“’We don’t allows dogs to breed. We spay them. We neuter them. We
try to keep them from having unwanted puppies, and yet these
women are literally having litters of children…. These women are not
getting pregnant because they love children, but because they’re
totally irresponsible.’”
Chelian, 2003, 191
“‘They’re going to do drugs with or without our money. But maybe our
money means they won’t rob someone tomorrow, or maybe it means
they won’t have to turn as many tricks the day after.’”
Adams, 2010
Question:
Supporting Project Prevention….
… how ethically defensible is it?
2. Incentives at the Individual Level
Incentivizing long-acting contraceptive use by people
who are substance users
- reasons in favour
- reasons against
Question:
Offering substance users cash incentives to use longacting contraceptives….
… how ethically defensible is this?
autonomy
ArtExplosion
Ichooz
ME
ArtExplosion
3. Incentives at the Group Level
Citizens’ health and well-being in context…
- the government’s mandate
- “architecture of choice”
- nudges versus shoves
A nudge is:
any aspect of the choice architecture that alters
people’s behavior in a predictable way without
forbidding any options
Thaler & Sunstein, 2012, 11
Question:
How might the explicit use of the concepts
- choice architecture
- nudges versus shoves
improve clinical practice?
Concluding Thoughts
“Do the means justify the ends?”
- need to assess the ethical defensibility of the ends, the means
and organization/individual’s character
Beware of autonomy hyperbole
work with “everyday people”
Examine how administrative practices may or may not contribute to
sustained improvements
 Questions?
 Challenges?
 Points/experiences to share?
Thank you.
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