Research on cash payments to promote health: Ethical concerns may be misplaced

It is fairly common for clinical research participants to receive payment for expenses such as travel and parking. What has raised ethical questions are payments or incentives given to encourage people to participate in research or to use a specific health intervention or care plan as part of the research.

In a paper published in , Carnegie Mellon University's Alex John London argues that when incentives are used to encourage people to engage in healthy activities from which they are likely to benefit, and with which they are already familiar, about the use of incentives may be misplaced.

"Current research ethics guidelines do not distinguish between giving a person money as an incentive to enroll in a research study and conducting a study to see if giving someone money as an incentive to stop smoking or to lose weight helps such people stop smoking or lose weight," said London, associate professor of philosophy within CMU's Dietrich College of Humanities and Social Sciences and director of the university's Center for Ethics and Policy.

Writing on behalf of the Ethics Working Group of the HIV Network, London and colleagues argue that ethical concerns that may be appropriate when considering incentives given to encourage participation in research may be out of place when considering incentives given to people to engage in healthy behavior.

"I know a lot of people who would like to quit smoking or lose some weight but who can't seem to stick to the relevant care plan," London said. "Researchers want to know if providing cash incentives for sticking with these plans will help people succeed. They also want to know if offering for early HIV testing or for seeking treatment after a positive test will improve patient care and help contain the spread of HIV. The only way to answer these questions is to study the use of such incentives in research."

London and his colleagues wrote, "Some common concerns about using incentives to increase participation in research, such as that attractive incentives will undermine participant autonomy, are misplaced when incentives are used to overcome economic obstacles or a lack of effective motivation, and when recipients are incentivized to engage in health-related behaviors or practices with which they are already familiar and which they regard as beneficial or worthwhile."

The authors recommend that Research Ethics Committees — the established bodies responsible for approving the ethical conduct of trials — should require researchers to provide an evidence-based rationale for predicting that the provision of an incentive will encourage the intended healthy behavior and not adversely affect the willingness of participants or community members to engage in that behavior.

"Research Ethics Committees should ensure, as far as possible, that the use of incentives to promote healthy behavior could be sustained in the context where research is conducted and would not represent an unreasonable use of scarce health resources," said London.

More information: London AJ, Borasky DA Jr, Bhan A, for the Ethics Working Group of the HIV Prevention Trials Network (2012) Improving Ethical Review of Research Involving Incentives for Health Promotion. PLoS Med 9(3): e1001193. doi:10.1371/journal.pmed.1001193

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