After the English health service announced it is going to reward drug addicts who comply with treatment programs by giving them shopping vouchers, an article in this week's British Medical Journal wonders whether it is acceptable to do this.
According to Tom Burns, a senior psychiatrist at Warneford Hospital, Oxford, rewarding patients who comply is not new. He added that the majority of mental health practitioners reward patients for 'health behavior'.
Some people wonder whether this practice may be seen as the 'exploitation of impoverished patients'. There is also concern about how the rewarded patient might spend the money. Burns writes that it is the circumstances that dictate whether a payment is a just reward or an immoral exploitation of a patient, not the transaction itself.
Burns goes on to say that he sees the act of rewarding a patient for complying as a refreshingly honest acknowledgement of the different perspectives of the two parties involved. It is not manipulative, he believes, but rather a model of respectful exchange.
Joanne Shaw, Chairman, Vice-Chairman, NHS Direct, believes otherwise. Shaw argues that payment is not the best way to solve the serious problem of non-adherence to medication. Payment affects the incentives in an undesirable way, Shaw believes. She writes that it undermines the therapeutic alliance the doctor and patient have - something crucial for long-term health care.
By bringing money into it we are opening up conditions for fraud, argues Shaw. This creates problem number one - policing the whole thing. Giving a person money to take medications might send a signal that the reward is for something that is not inherently in their own interests. Solving the problem of non-drug adherence is not easy, she writes. However, paying is not the solution.
Head to Head: Is it acceptable for people to be paid to adhere to medication? No
Joanne Shaw
BMJ 2007;335:233 (4 August), doi:10.1136/bmj.39286.422639.BE
Click here to see abstract online
Is it acceptable for people to be paid to adhere to medication? Yes
Tom Burns
BMJ 2007;335:232 (4 August), doi:10.1136/bmj.39286.399514.BE
Click here to see abstract online