chapter  23
10 Pages

Incentives in Health: Ethical Considerations

WithRICHARD ASHCROFT

The use of incentives is an increasingly popular technique in health promotion (Oliver and Brown 2012). The central idea is this. A person currently has a pattern of behavior which has an impact on their current or future health. Although adopting a different “health behavior” would improve their current or future health, they are unwilling or unable to do so. Other methods of changing this behavior (typically, advice and information-giving, or personal resolution-making) may have been tried but without any, or without consistent, success. The behavior itself may involve no direct harm to others, so that direct coercion may not be permissible. The behavior is sufficiently under the voluntary control of the person that a “hard paternalist” justification for forcibly changing the person’s behavior for their own sake (as opposed to for the prevention of harm to others) is also lacking. Under these circumstances, an incentive may be offered to the person, in the hope that their desire for the incentive is sufficiently strong that they will change their behavior in order to earn the incentive. And further, having changed their behavior, and earned the incentive, their behavior will now not revert to the previous, undesirable behavioral pattern. Although this account of incentives gives a good indication of why incentives in health behavior change may be a good idea, there are some frequently identified moral problems which may afflict incentive schemes, at least sometimes. They may be coercive (the idea of “the offer you cannot refuse”); they may be corrupting (if people are induced by the offer of an incentive to act against their own principles or to seek to be paid where they should act from duty); they may be unfair (if some people are “rewarded” for a change in behavior but others are not, or if certain kinds of people are unfairly singled out for intervention where others are left alone).