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...

In this paper I analyze the alleged conflict between economic incentives to efficiently utilize health care resources and the obligation to provide patients with the best possible medical care. My analysis is developed in four stages. First, I discuss briefly the nature of prospective payment systems and economic incentives as well as the issue of professional autonomy. Second, I disscuss the notion of an incentive for action both as an economic incentive and as a concept of moral (...) psychology. Third, I analyze several definitions of the physician's professional obligation and discuss four conditions that morally qualify the obligation. And fourth, I explore why the views of economists and physicians differ so strikingly on the question of economic incentives. In the process of this analysis, I argue that criticisms of prospective payment systems which are premised primarily on the conflict between economic incentives to contain cost and the professional obligation of beneficence are probably as much a matter of rhetoric as serious argumentation. Keywords: autonomy, beneficence, cost containment, economic incentives, moral obligation, prospective payment CiteULike Connotea Del.icio.us What's this? (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)

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.

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.

The practice of paying prisoners to for their participation in research has long been debated, and the controversy is reflected in the differing policies in the U.S. prison systems. Empirical study of financial payments to inmates who enroll in research has focused on whether this practice is coercive. In this study, we examined whether monetary incentives have the potential to be unduly influential among fifty HIV‐positive prisoners. The majority of prisoners surveyed believed that inmates should receive some compensation for (...) their involvement in research and disagreed with statements suggesting that the offer of payment constitutes undue influence. However, a sense of potentially being susceptible to undue influence was significantly higher among participants who had spent a longer time in prison and had less education. Overall, our findings suggest that most prisoners feel that they would be able to make a decision about research enrollment that is not solely based on an offer of monetary payment. (shrink)

Philippe van Parijs (2003) has argued that an egalitarian ethos cannot be part of a post- Political Liberalism Rawlsian view of justice, because the demands of political justice are confined to principles for institutions of the basic structure alone. This paper argues, by contrast, that certain principles for individual conduct—including a principle requiring relatively advantaged individuals to sometimes make their economic choices with the aim of maximising the prospects of the least advantaged—are an integral part of a Rawlsian political conception (...) of justice. It concludes that incentive payments will have a clearly limited role in a Rawlsian theory of justice. (shrink)

This article considers the ethical implications of prospective payment from the perspective of physicians and other health care practitioners. It focuses on the argument that prospective payment creates ethical conflict by giving physicians an economic incentive to do less for their patients. This argument is criticized in two respects. First, available evidence is reviewed which suggests that the incentives actually created by different prospective payment schemes and their effect on "optimal" patterns of practice is uncertain. Further, (...) it is pointed out that ethical conflict originates in the dual role of physicians as agents and suppliers of service. Recognizing that such conflict exists under any payment mechanism, a better focus for the ethical evaluation of prospective payment is suggested that considers whether the incentive to do less is likely to have adverse effects on physician decisions, relative to decisions made under other payment mechanisms. Keywords: incentives, utilization, conflict of interest, efficiency, justice, agent CiteULike Connotea Del.icio.us What's this? (shrink)

If someone claims that individuals behave as if they violate the independence axiom when making decisions over simple lotteries, it is invariably on the basis of experiments and theories that must assume the IA through the use of the random lottery incentive mechanism. We refer to someone who holds this view as a Bipolar Behaviorist, exhibiting pessimism about the axiom when it comes to characterizing how individuals directly evaluate two lotteries in a binary choice task, but optimism about the axiom (...) when it comes to characterizing how individuals evaluate multiple lotteries that make up the incentive structure for a multiple-task experiment. We reject the hypothesis about subject behavior underlying this stance: we find that preferences estimated with a model that assumes violations of the IA are significantly affected when one elicits choices with procedures that require the independence assumption, as compared to choices elicited with procedures that do not require the assumption. The upshot is that one cannot consistently estimate popular models that relax the IA using data from experiments that assume the validity of the RLIM. (shrink)

Philippe van Parijs (2003) has argued that an egalitarian ethos cannot be part of a post- Political Liberalism Rawlsian view of justice, because the demands of political justice are confined to principles for institutions of the basic structure alone. This paper argues, by contrast, that certain principles for individual conduct—including a principle requiring relatively advantaged individuals to sometimes make their economic choices with the aim of maximising the prospects of the least advantaged—are an integral part of a Rawlsian political conception (...) of justice. It concludes that incentive payments will have a clearly limited role in a Rawlsian theory of justice. (shrink)

Philippe van Parijs (2003) has argued that an egalitarian ethos cannot be part of a post- Political Liberalism Rawlsian view of justice, because the demands of political justice are confined to principles for institutions of the basic structure alone. This paper argues, by contrast, that certain principles for individual conduct—including a principle requiring relatively advantaged individuals to sometimes make their economic choices with the aim of maximising the prospects of the least advantaged—are an integral part of a Rawlsian political conception (...) of justice. It concludes that incentive payments will have a clearly limited role in a Rawlsian theory of justice. (shrink)

:A common justification offered for unequal pay is that it encourages socially beneficial productivity. G. A. Cohen famously criticizes this argument for not questioning the behaviour and attitudes that make those incentives necessary. I defend the communal status of incentives against Cohen's challenge. I argue that Cohen's criticism fails to appreciate two different contexts in which we might grant incentives. We might grant unequal payment to someone because they demand it. However, unequal payment might be (...) an offer instead. I claim that incentives as offers promote the ideal of society as a cooperative venture for mutual advantage. (shrink)

In order to assess to the degree to which the provision of economic incentives can result in justified inequalities, we need to distinguish between compensatory incentive payments and non-compensatory incentive payments. From a liberal egalitarian perspective, economic inequalities traceable to the provision of compensatory incentive payments are generally justifiable. However, economic inequalities created by the provision of non-compensatory incentive payments are more problematic. I argue that in non-ideal circumstances justice may permit and even require the provision of non-compensatory (...) class='Hi'>incentives despite the fact that those who receive non-compensatory payments are not entitled to them. In some circumstances, justice may require us to accede to unreasonable demands for incentive payments by hard bargainers. This leads to a kind of paradox: from a systemic point of view, non-compensatory incentive payments can be justified even though those who receive them have no just claim to them. (shrink)

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)

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)

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)

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)

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 a recent article (“The current state of the platelet supply in the US and proposed options to decrease the risk of critical shortages”) published in _Transfusion,_ Stubbs et al. have argued that platelet donors should be paid. Dodd et al. have argued against this proposal, supporting their response with survey data that shows that blood donors (and by extension platelet donors) and potential platelet donors are uninterested in receiving incentives to encourage them to donate. Instead, argue Dodd et (...) al., prospective platelet donors are motivated more by the ease of donation than the prospect of payment. This article defends Stubbs et al. from the criticisms of Dodd et al. It first argues that the preferences that persons state they have in response to survey questions might not reflect the preferences that their actions would reveal they have in actual rather than hypothetical situations. This hypothetical bias is especially likely when persons respond to surveys that ask them about the performance of morally commendable actions (such as platelet donation). This article then argues that the survey that Dodd et al. rely on exhibits serious selection bias with respect to the set of persons it considers to be potential platelet donors. (shrink)

In their Target Article, “Promoting Ethical Payment in Human Infection Challenge Studies,” Lynch et al. propose a framework for ethical payment to research participants and apply it to the c...

We design a project funding contract that provides optimal incentives to agents, in a setting where both principal and agent enjoy the benefits of the project in a non-rival form once completed but may differ in their valuation. To do so, we study optimal incentive payments in a dynamic principal-agent framework in which the principal cannot observe the agent’s investment, but only completed projects, and faces a Samaritan’s Dilemma: he cannot commit to terminate the contract before completion of the (...) project. The agent decides whether to undertake a investment or consume all received funds. We find that the optimal contract is stationary, and that either transfers equal to investment cost are incentive compatible or the cost of the contract is decreasing with the agent’s valuation of the projects. Given the intrinsic valuation of the project by the agent, he is always better off signing the contract in contraposition with the general moral hazard result. (shrink)

The current Medicare prospective payment system has many positive incentives for hospitals to control costs. Hospitals are increasing outpatient surgery, decreasing admissions, decreasing length of stay, and decreasing use of ancillary services. These are just the effects that Congress and the Health Care Financing Administration hoped for to save the Medicare trust fund. However, there has been evidence of some adverse outcomes including premature discharge, “dumping” sicker patients and patients without insurance, and adverse impact on hospitals with specialty (...) centers. We examine these issues and present a possible solution based on a new Computerized Severity Index. (shrink)

Rapid, large-scale uptake of new vaccines against COVID-19 will be crucial to decrease infections and end the pandemic. In a recent article in this journal, Julian Savulescu argued in favour of monetary incentives to convince more people to be vaccinated once the vaccine becomes available. To evaluate the potential of his suggestion, we conducted an experiment investigating the impact of payments and the communication of individual and prosocial benefits of high vaccination rates on vaccination intentions. Our results revealed that (...) none of these interventions or their combinations increased willingness to be vaccinated shortly after a vaccine becomes available. Consequently, decision makers should be cautious about introducing monetary incentives and instead focus on interventions that increase confidence in vaccine safety first, as this has shown to be an especially important factor regarding the demand for the new COVID-19 vaccines. (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.

: Free-market libertarians have long supported incentives to increase organ procurement, but those oriented to justice traditionally have opposed them. This paper presents the reasons why those worried about justice should reconsider financial incentives and tolerate them as a lesser moral evil. After considering concerns about discrimination and coercion and setting them aside, it is suggested that the real moral concern should be manipulation of the neediest. The one offering the incentive (the government) has the resources to eliminate (...) the basic needs that pressure the poor into a willingness to sell. It is unethically manipulative to withhold those resources and then offer payment for organs. Nevertheless, the poor have been left without basic necessities for 20 years since the passage of the prohibition on incentives. As long as the government continues to withhold a decent minimum of welfare, liberals should, with shame, cease opposing financial incentives for organ procurement. (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)

A number of schemes have been attempted, both in public health and more generally within social programmes, to pay individuals to behave in ways that are presumed to be good for them or to have other beneficial effects. Such schemes are normally regarded as providing a financial incentive for individuals in order to outweigh contrary motivation. Such schemes have been attacked on the basis that they can ‘crowd out’ intrinsic motivation, as well as on the grounds that they are in (...) some sense ‘corrupt’. In response, they have been defended on the grounds that they can ‘crowd in’ improved motivation. I will argue that these debates have tended to overlook the difficulties individuals can have when attempting to behave against peer group norms. In some cases, financial payments can allow individuals to defend their actions on the grounds that ‘I am only doing it for the money’ in circumstances when it would be difficult to defend their action on their real motivations. Examples of paying children to read books, and paying women to give up smoking in pregnancy, will be discussed. (shrink)

G. A. Cohen 's critique of Rawlsian special incentives has been criticised as internally inconsistent on the grounds that Cohen concedes the existence of incentives that are legitimate because they are grounded on agent-centred prerogatives. This, Cohen 's critics argue, invites a slippery slope argument: there is no principled line between those incentives Cohen permits and those he condemns. This paper attempts a partial defence of Cohen : a prerogative can be granted but then its operation internally (...) qualified. A better off person has a prerogative that grounds incentive payment, but that person should be sensitive to the degree of difference between her resources and those of the representative worst off person. This gives a better off person under a distribution a discretion that is then internally qualified by a commitment to an egalitarian ethos. The paper concludes that on balance this is not, in fact, a reasonable view of a prerogative: granting it and then qualifying it in this way undermines the unfettered discretion that should attach to a prerogative. However, Cohen has certainly identified an ambiguity in how we conceive of prerogatives. (shrink)

The use of high hypothetical payoffs has been justified by the realism and relevance of large monetary consequences and by the impracticality of making high cash payments. We argue that subjects may not be able to imagine how they would behave in high payoff situations.

The deposit insurance makes the value of deposits independent from the behavior of other depositors or from the value of bank assets. Its existence induces a moral hazard which might threaten the stability of the banking system. The efficiency of the DI depends on the control of moral hazard, which means the agents’ responsibilisation, depositors included. There is a conflict between the DI principles and the present propositions improving this mechanism.The possible solutions in order to solve this paradox are the (...) restriction of the insurance coverage only for the demand deposits and the implementation of the double liability for the bank shareholders.The demand deposits insurance eliminates the incentive to bank runs caused by the fear of lack of liquidity, whereas the term deposits are exposed to losses which reduce the moral hazard induced by the demand deposit insurance.The double liability forces the shareholders of the defaulting banks to make supplementary payments limited to the nominal value of the owned shares. This combines the advantages of the limited liability and the unlimited liability.The efficiency of both propositions implies the enforcement of a closure rule of the banks whose net worth is close to zero.La garantie des dépôts rend la valeur des dépôts indépendante du comportement des autres déposa- nts ou de la valeur des actifs bancaires. Son instauration induit un aléa moral qui peut menacer la stabilité du système bancaire. L’efficacité de ce mécanisme dépend de la maîtrise de l’aléa moral. Cela suppose, entre autres, la responsabilisation des agents, y compris des déposants. Par conséquent, il existe un conflit entre le principe de la garantie des dépôts et les propositions courantes d’amélioration de ce dispositif.Les solutions envisagées dans cet article pour résoudre ce paradoxe sont la limitation de la garantie aux seuls dépôts à vue et l’instauration de la double responsabilité pour les actionnaires des banques.La garantie des dépôts à vue élimine l’incitation à la ruée due à la crainte de manque de liquidité, tandis que les dépôts à terme sont assortis d’une clause permettant à la banque de refuser tout retrait anticipé. Les titulaires des dépôts à terme s’exposent à des pertes, ce qui réduit l’aléa moral induit par la garantie des dépôts à vue.La double responsabilité oblige les actionnaires des banques défaillantes à effectuer des versements supplémentaires dans la limite de la valeur nominale des actions détenues. Cela réunit les avantages de la responsabilité limitée et de la responsabilité illimitée.L’efficacité des deux propositions suppose l’application d’une règle de fermeture des banques dont l’actif net avoisine zéro. (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 use of high hypothetical payoffs has been justified by the realism and relevance of large monetary consequences and by the impracticality of making high cash payments. We argue that subjects may not be able to imagine how they would behave in high payoff situations.

We argue that we should provide extra payment not only for extra time worked but also for the extra risks healthcare workers (and those working in healthcare settings) incur while caring for COVID‐19 patients—and more generally when caring for patients poses them at significantly higher risks than normal. We argue that the extra payment is warranted regardless of whether healthcare workers have a professional obligation to provide such risky healthcare. Payment for risk would meet four essential ethical (...) requirements. First, assuming healthcare workers do not have a professional obligation to take on themselves the risks, payments in the form of incentives would preserve autonomy in deciding what risks to take on oneself. Second, even assuming that healthcare workers do have a professional obligation to take on themselves the risks, payments for risk would create fair working conditions by avoiding exploitation. Third, payments for risk would make it more likely that public healthcare systems can discharge their institutional responsibility to provide healthcare in circumstances where healthcare workers may otherwise (perhaps legitimately) opt out. Fourth, payments for risk would guarantee an efficient healthcare system in pandemic situations. Finally, we address two likely objections that some might raise against our proposal, particularly with regard to incentives, namely that such payments or incentives can themselves be coercive and that they represent a form of undue inducement. (shrink)

Actions that financially benefit one person may present risk to another person. For example, the payment incentives of portfolio managers and investors are often asymmetrical such that actions that benefit a portfolio manager can pose financial risk to clients. Despite the presence and potential harm of these asymmetries, few have addressed the question of who exploits these asymmetries and how to mitigate potential harm. Our study examined the effect of selfish personality traits (the Dark Triad) and interpersonal bonding (...) on decision-making for the self, another person, and another person with under reward asymmetry present. Results demonstrated that individuals higher in narcissism and psychopathy made risky decisions for themselves. However, when reward asymmetries were present, all three Dark Triad traits were associated with making riskier decisions for another person in order to benefit the self. There was also a significant interaction between interpersonal closeness generated through bonding and psychopathy such that bonding made the decision-making processes of those high in psychopathy less risky for others. These findings have implications for how different individuals with different relationships make self and other-based financial decisions, and how those decisions change when rewards are asymmetrical. (shrink)

Acts of helping others are often based on mixed motivations. Based on this claim, it has been argued that the use of a financial reward to incentivize organ donation is compatible with promoting altruism in organ donation. In its report Human Bodies: Donation for Medicine and Research, the Nuffield Council on Bioethics uses this argument to justify its suggestion to pilot a funeral payment scheme to incentivize people to register for deceased organ donation in the UK. In this article, (...) I cast a sceptical eye on the above Nuffield report's argument that its proposed funeral payment scheme would prompt deceased organ donations that remain altruistic . Specifically, I illustrate how this scheme may prompt various forms of mixed motivations which would not satisfy the report's definition of altruism. Insofar as the scheme produces an expectation of the reward, it stands diametrical to promoting an ‘altruistic perspective’. My minimal goal in this article is to argue that altruism is not motivationally compatible with reward as an incentive for donation. My broader goal is to argue that if a financial reward is used to incentivize organ donation, then we should recognize that the donation system is no longer aiming to promote altruism. Rewarded donation would not be altruistic but it may be ethical given a persistent organ shortage situation. (shrink)

When payment is offered for controlled human infection model research, ethical concerns may be heightened due to unfamiliarity with this study design as well as perceptions—and misperceptions—regarding risk. Against this backdrop, we commend Grimwade et al 1 for their careful handling of the relevant issues, coupling empirical and conceptual approaches. We agree with foundational elements of the authors’ analysis, including the acceptability of payment for research risk.1 However, in our view, it is preferable to treat payment for (...) risk as a discretionary incentive to achieve adequate recruitment and retention, rather than compensation owed as a matter of fairness. Grimwade et al 1 note that although their ‘Payment for Risk Model’ was ‘created specifically in the context of CHIM research, it has the potential to inform payment in other areas of medical research.’ We agree and would go further: we do not need a special payment framework for CHIMs because there is nothing so novel about them compared with other types of research as to demand a distinct approach. Any successful payment framework must address the following ethical issues: preserving informed consent ; treating participants fairly ; encouraging adequate recruitment and retention; avoiding deception by participants; and preserving public trust.2 Some of these issues may have particular salience in the context of CHIMs, but this study design does not demand consideration of entirely distinct ethical factors when evaluating offers of payment.2 We also agree with Grimwade et al 1 about several other key points.2 Given the burdens involved and …. (shrink)

This paper explores problems associated with using altruism as the central value in gamete donation, and in doing so draws on empirical data that sheds light on why gamete donors choose to donate. Donation of bodily material is, arguably, supposed to be motivated by altruism, and this is the view taken by many European governments. Other values are often ignored or rejected as morally inappropriate. This paper analyses some conceptual and practical problems with the use of altruism as the motivation (...) to determine moral acceptability—drawing on empirical data that suggests gamete donors are not motivated purely by altruism, and that motivations are in fact quite complex. Two problems are first analysed: how do we distinguish altruistic from non-altruistic donations and how do we distinguish between removing barriers and providing incentives. A final question, triggered by the Nuffield Council on Bioethics’ report, is whether the meaning of the payment should be decided on the basis of an a priori definition or on the basis of the donors’ subjective experience. It is concluded that there are different legitimate core values in donation, which should be balanced. In order to value the good generated by donation, donors with mixed motives should be accepted, as long as helping others is an important motive and also features in their motivation. (shrink)

G.A. Cohen criticizes Rawls’s account of justice because his difference principle permits inequalities that reflect the relative scarcity of different skills and natural abilities. Instead of viewing the ‘basic structure’ as the primary subject of justice, Cohen argues that individual citizens should cultivate an egalitarian ethos, which would enable a just society to dispense with the use of incentive payments to induce individuals to use their talents in socially ideal ways. This study examines Cohen’s critique, including his rejection of ‘ (...) class='Hi'>incentives,’ and vindicates Rawls’s approach. Ultimately, Cohen’s argument fails to grapple with the moral pluralism that characterizes modern, democratic societies, whereas Rawls’s theory is constructed to accommodate such pluralism. (shrink)

Payment for performance is widely embraced as a key component of any well-designed executive compensation package. There is a price to be paid, however, for the heavy reliance on incentives as a way of controlling agent behavior. In particular, evidence exists demonstrating that incentives can crowd out an agent’s social preferences towards her principal. Social preferences are pro-social tendencies of people to do things for others for reasons such as fairness, reciprocity, altruism, and ethical or moral beliefs. (...) The use of incentives in compensation can result in self-interested agents. When crowding out occurs, in order to elicit the desired level of performance, principals may need to increase the level of incentive employed. Crowding out therefore provides an additional account for rising levels of executive compensation. In addition, crowding theory can provide a helpful explanation for the tension around the U.S. government’s reaction to preexisting banker incentive contracts during the 2008 financial crisis. (shrink)

Much has been written about medicine and the market in recent years. This book is the first to include an assessment of market influence in both developed and developing countries, and among the very few that have tried to evaluate the actual health and economic impact of market theory and practices in a wide range of national settings. Tracing the path that market practices have taken from Adam Smith in the eighteenth century into twenty-first-century health care, Daniel Callahan and Angela (...) A. Wasunna add a fresh dimension: they compare the different approaches taken in the market debate by health care economists, conservative market advocates, and liberal supporters of single-payer or government-regulated systems. In addition to laying out the market-versus-government struggle around the world -- from Canada and the United States to Western Europe, Latin America, and many African and Asian countries -- they assess the leading market practices, such as competition, physician incentives, and co-payments, for their economic and health efficacy to determine whether they work as advertised. This timely and necessary book engages new dimensions of a development that has urgent consequences for the delivery of health care worldwide. (shrink)

This target article is concerned with the implications of the surprisingly different experimental practices in economics and in areas of psychology relevant to both economists and psychologists, such as behavioral decision making. We consider four features of experimentation in economics, namely, script enactment, repeated trials, performance-based monetary payments, and the proscription against deception, and compare them to experimental practices in psychology, primarily in the area of behavioral decision making. Whereas economists bring a precisely defined “script” to experiments for participants to (...) enact, psychologists often do not provide such a script, leaving participants to infer what choices the situation affords. By often using repeated experimental trials, economists allow participants to learn about the task and the environment; psychologists typically do not. Economists generally pay participants on the basis of clearly defined performance criteria; psychologists usually pay a flat fee or grant a fixed amount of course credit. Economists virtually never deceive participants; psychologists, especially in some areas of inquiry, often do. We argue that experimental standards in economics are regulatory in that they allow for little variation between the experimental practices of individual researchers. The experimental standards in psychology, by contrast, are comparatively laissez-faire. We believe that the wider range of experimental practices in psychology reflects a lack of procedural regularity that may contribute to the variability of empirical findings in the research fields under consideration. We conclude with a call for more research on the consequences of methodological preferences, such as the use on monetary payments, and propose a “do-it-both-ways” rule regarding the enactment of scripts, repetition of trials, and performance-based monetary payments. We also argue, on pragmatic grounds, that the default practice should be not to deceive participants. Key Words: behavioral decision making; cognitive illusions; deception; experimental design; experimental economics; experimental practices; financial incentives; learning; role playing. (shrink)